Tapering of prednisone in RA patients who achieved low disease activity or remission with tocilizumab

Tapering prednisone, while remaining in at least low disease activity, may be an option for nearly two-thirds of rheumatoid arthritis (RA) patients who achieved remission or low disease activity on tocilizumab and low-dose prednisone.

According to current guidelines, patients with RA should typically receive the lowest necessary dose of glucocorticoid treatment, while avoiding doses ≥5 mg/day for longer than 3 to 6 months. However, many early or established RA patients receive ≥5 mg/day or higher doses varying between 3 up to 24 months. In addition, Prof. Gerd Burmester (Free University and Humboldt University of Berlin, Germany) noted in an interview that “physicians largely rely on personal experience when tapering glucocorticoids.” There is a lack of methodologically, appropriate clinical trials and guidelines for when and how to taper glucocorticoids, including prednisone.

Prof. Burmester compared glucocorticoid tapering versus continuation to maintain disease control in patients with RA who were receiving a stable combination of prednisone (5 mg/day), in addition to tocilizumab with or without csDMARDs for ≥4 weeks. A total of 259 patients were included in this multicentre, double-blind, randomised controlled trial. Prior to randomisation, patients had at least low disease activity defined as DAS28-ESR ≤3.2 or less. Patients randomised to the tapering group (n=131) received 1 mg/day reduction every 4 weeks and stopped taking the prednisone entirely between 16 and 24 weeks, whereas patients who continued on glucocorticoid therapy (n=128) received 5 mg/day over the 24-week period.

Disease was controlled better in patients who continued treatment compared with tapering (DAS28-ESR decrease by 0.075 and increase by 0.538 compared to baseline, respectively; P<0.001). Overall, 65% of patients in the tapering and 77% of patients in the continuation arm achieved ‘treatment success’, defined as staying in at least low disease activity, lack of flare, and lack of adrenal insufficiency. Flares occurred among 26% of patients in the tapering arm and in 11% of patients in the continuation arm. There were no discontinuations in the tapering arm as a result of insufficient flare control, compared with one patient in the continuation arm. With regard to safety, 3% of patients in the tapering arm and 5% of patients in the continuation arm experienced serious adverse events.

1. Burmester GR, et al. Abstract OP0030. EULAR 2019

Posted on 4 September, 201927 March, 2024