Disease activity-driven dose reduction in patients with RA treated with b/ts DMARDs is not associated with radiographic progression, DRESS trial finds.

Is disease activity–guided dose optimization of biologic/targeted synthetic (b/ts) disease-modifying antirheumatic drugs (DMARDs) a viable, long-term option in the management of rheumatoid arthritis (RA)? This is the question that an observational extension study of the DRESS trial (Dutch Trial Register, NTR 3216) tried to answer. The initial parts of the trial found that lengthening the tumor necrosis factor inhibitors (TNFi) treatment intervals in stable patients with RA using a disease activity-driven strategy can be successful, safe, and cost-effective. In the current part of the study, patients were followed from year 3 to year 10. “It is important to measure disease activity and set a goal (eg, Disease Activity Score [DAS]28, as well as to increase the dose when the disease activity increases above a certain threshold,” Noortje van Herwaarden, PhD, explained, at EULAR 2023, held May 31-June 2, in Italy. The mean time-weighted disease activity was measured by DAS28-CRP.

Most of the 170 patients in the study cohort were women (64%), the mean age was 59, and RA was present at an average of 10 years. About 60% already had erosive disease at baseline. “Disease activity remained low throughout the years,” Dr. van Herwaarden stated, referring to a DAS28-CRP of just over 2. The TNFi doses decreased from the baseline 97% of the defined daily dose (DDD) to 49% at year 5, and to 51% at year 10. Looking at all b/ts DMARDs, the respective percentage of the DDD was 97% (year 0) and 56% (years 5 and 10). At a median, patients had two attempts of dose optimization, and in 74% of cases, a tapering to full discontinuation was achieved. The first discontinuation attempt lasted a median of 7 months, and there was a median of 6.8-year drug survival after restarting medication or increasing dosage.

Additionally, “radiographic progression exceeding the smallest detectable change was associated independently with disease activity, but not with b/ts DMARD dose,” Dr. van Herwaarden said. “Good quality treat-to-target is important to mitigate radiographic joint damage,” she emphasized.

In conclusion, these findings suggest that disease activity-guided dose optimization yields stable low disease activity over time.

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