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The influence of tapering bDMARDs medication on CVD risk in patients with inflammatory rheumatic diseases
#1
Calin Popa


02-06-2022 14:27
Background: Rheumatoid arthritis (RA) is associated with 1.5-2.5 higher CV risk, mostly due to inflammation, disease activity and medication. Accordingly, RA-related factors would account for approximately 30% of all CVD events occurring in this population. Conversely, achieving longstanding remission and/or low disease activity (LDA) states would positively impact CV risk in RA [1,2]. In following the treat-to-target approach to treat their patients and putting in balance the therapeutic benefits as well as the putative risks and side effects of each therapeutic step taken, rheumatologists often face the dilemma whether therapy should be continued at the same intensity/level once remission or LDA is achieved.

In the past years, it has been shown that tapering/stopping of biological disease modifying anti-rheumatic drugs (bDMARDs) in patients with RA is compatible with maintaining remission and/or LDA in a large proportion of them. This is associated with clear benefits including increased cost-effectiveness and less patient burden due to self-injection. However, other advantages are still less clear, including the assumed lower risks of (dose dependent) side-effects associated with these drugs, mainly infections. Also, whereas most bDMARDs have been suggested to decrease the risk of cardiovascular disease, it is yet unknown what the effect of tapering would be in this respect [3]. Finally, tapering studies have provided some indications (although not significantly) that patients tapering the bDMARD might develop another inflammatory disease like PMR [4].

Aim of the study: to assess the long-term effects of disease activity guided tapering and/or stopping of bDMARDs in patients with inflammatory arthropathies (not just only RA, but also PsA and AS) on the risk of developing cardiovascular diseases (CVD).

Methods
Who and what?
P: We will focus on patients with one of the following inflammatory rheumatic condition: rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS).
I: treatment episodes with bDMARDs less than the recommended dose (tapering).
C: treatment episodes with use of DMARDS in concordance with the recommended dose (non-tapering).
O: primary outcome will be incidence (Cumulative incidence, incidence density, time-to-event), type and severity of cardiovascular diseases.

How?
A large monocenter cohort database of all RA, AS and PsA patients treated from 2012 to 2021 that has been developed in recent years is used
(IRIS). We have to our disposal a pool of approximately 7,000 patients with 25,000 patient years follow up, with estimated 2600 bDMARD patients of whom 50% were tapered treated to target during some period. Available data within this cohort includes demographics, disease characteristics, medication use, disease activity measurements and laboratory values. Outcome assessment has to be done by:
- abstracting data from medical history and patient chart notes. It is the intention to use queries for these aims, in order to speed up the acquiring process of data and to increase the completeness of it (already developed).
 using mixed model analysis in order to assess the effects of intensity of (b)DMARD treatment on CVD on our cohorts


References
1. Arts E et al. Ann Rheum Dis 2017; 76:1693-9.
2. Crowson CS et al. Ann Rheum Dis 2018; 77:48-54
3. Kim HW et al. Rheumatol Int 2015; 35:727-34
4. Bouman CA et al. Ann Rheum Dis 2017; 76:1716-22.