Australian recommendations favour a reduction of b/tsDMARD dose in people with rheumatoid arthritis or axial spondyloarthritis who have achieved a stable low disease activity state.
However the Australia and New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network made a conditional recommendation against dose modification in people with psoriatic arthritis due to lack of evidence.
Sudden discontinuation of bDMARDs was more likely to be associated with a disease flare in all three inflammatory conditions.
The guidance noted that patients who use bDMARDs were often interested in reducing their dose when the disease is under control in the hope that this might reduce inconvenience and potential toxicity.
“However this is balanced by concerns that dose reduction might result in a disease flare and that resumption of the full dose might not achieve the previous level of disease control,” it said.
“Although data from trials suggest that at least 80 percent of those who flare will regain disease control with resumption of the previous dose of b/tsDMARD, the risk of incomplete or delayed restoration of the previous level of disease control is likely to be an important consideration, particularly for individuals who place a high value on the avoidance of disease flare.”
It suggested that “an individualised shared decision-making framework” was of particular importance.
The authors noted that most evidence was from patients using TNF inhibitors particularly adalimumab and etanercept.
The recommendations, partly supported by a Commonwealth Government Value in Prescribing Program Grant, said bDMARDs were expensive therapies that contribute significantly to the overall cost of PBS-funded medications in Australia.
“Use of lower doses of b/tsDMARDs may reduce the overall cost to the healthcare system, and may reduce out-of-pocket costs for patients.”