Sudden stop vs tapered adalimumab in IA: Which is best?

P atients with well-controlled inflammatory arthritis (IA) who abruptly discontinue adalimumab are likely to have higher flare rates than those who taper this medication or another tumor necrosis factor inhibitor (TNFi). In addition, patients who take the gradual approach are more likely to recover well-controlled disease when medications are restarted after a flare. These were the major findings of a review of 49 studies evaluating TNFis in rheumatoid arthritis (RA), ankylosing spondylitis, psoriatic arthritis, and juvenile idiopathic arthritis (JIA). Most studies reported TNFi outcomes as a single entity, with only a few evaluating adalimumab alone. Further, the authors noted that the studies varied in design, follow-up, follow-up duration, specificity for TNFi results, and controlled pediatric studies.

The 40 studies on RA, including 8 randomized controlled trials (RCTs), reported flare rates from 33% to 87%. Compared with an abrupt stop to medication, tapering was associated with slightly fewer flares, and successful recapture, at 80% to 100%, was generally high. The 12 studies on spondyloarthropathy, including 4 RCTs, noted that tapering rather than abruptly stopping medication resulted in both lower flare rates and high recapture rates of about 90%. All 5 JIA studies were observational. They showed lower flare rates with tapering (17% to 63%) than with stopping (28% to 82%). As for recapture rates, the limited pediatric data (from 3 studies) suggest that they are similar for tapering (63% to 100%) and abrupt stopping (83%).

Thoughts from Dr. Farber

One concern with newer medicines is whether treatment will negatively impact remission rates. This paper suggests that when using adalimumab for JIA, there is a good likelihood of remission and successful retreatment of relapses, if applicable. When to discontinue treatment, and whether tapering or abrupt discontinuation is preferred, will require further study.

Reference

Balay-Dustrude E, Fennell J, Baszis K, et al; CARRA JIA Inactive Disease Workgroup. Approaches and outcomes of adalimumab discontinuation in patients with well-controlled inflammatory arthritis: a systematic search and review. Pediatr Rheumatol Online J. 2024;22(1):112. doi:10.1186/s12969-024-01046-3