Comparative efficacy and safety of disease-modifying antirheumatic drugs tapering strategies in sustained-remission rheumatoid arthritis: Systematic review and network meta-analysis
In brief
Gradual biologic dose cuts had the lowest flare risk among tapering strategies
Across 19 studies and 3,115 adults with rheumatoid arthritis in sustained remission, tapering overall nearly doubled flare risk compared with continuing treatment. Gradually reducing biologic doses while continuing conventional drugs had the closest flare profile to maintenance, though the estimate was uncertain; stopping biologics while continuing conventional drugs was linked to about three times the flare risk.
- Journal
- Seminars in arthritis and rheumatism (Q1)
- Published
- 19 September 2026
- Study design
- Systematic review of cohort studies
- Evidence level
- Level 2, Moderate (CEBM 2a)
- Authors
- Yosi Yohanes Putra Tandi, Muhammad Yasir Syafa'atulloh, Yitzchak Millenard Sigilipu, Garuda Nusantara Putra Utomo, Muhammad Abdir Rahman Albarok, Stephen Hilkia Pramatya, et al.
- PMID
- 42843067
- DOI
- 10.1016/j.semarthrit.2026.153082
Why clinicians should know about it
- Picked for Rheumatology (paper of the day, 11 October 2026): Gradual bDMARD dose reduction showed most favourable flare profile
Abstract
BACKGROUND: International guidelines permit tapering disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis (RA) in sustained remission, but the de-escalation strategy with the lowest risk of flare remains unknown. Therefore, this study aimed to compare and rank flare risk across DMARD de-escalation strategies to guide more specific clinical decisions. METHODS: We performed a systematic review and a frequentist random-effects network meta-analysis (NMA) of clinical studies, evaluating DMARD tapering in adults with RA in remission (≥6 months). The primary network compared maintenance therapy (N0), simultaneous dose reduction of cDMARDs and bDMARDs (N1), discontinuation of bDMARDs while continuing cDMARDs (N3), and dose reduction of bDMARDs while continuing cDMARDs (N4). Flare risk was pooled as RR (95% CI) using a consistency model, with ranking by P-scores. Assessments of risk of bias, network inconsistency, and confidence in network estimates using CINeMA, as well as sensitivity analysis including complete DMARD withdrawal (N2), were also conducted. RESULTS: nineteen studies involving 3115 participants were included. Overall, tapering DMARDs increased the risk of flares compared with continued therapy (RR 1.94; 95%CI: 1.30-2.89). The primary NMA showed that tapering bDMARDs while continuing cDMARDs (N4) had the most favourable flare profile among the evaluated de-escalation strategies and was closest to maintenance therapy (RR 1.17; 95%CI: 0.76-1.82). In contrast, discontinuation of bDMARDs while continuing cDMARDs (N3) increased flare risk compared to N0 (RR 3.06; 95% CI: 1.81-5.16), and compared to N4 (RR 2.61; 95% CI: 1.44-4.72). The order of strategies identified was N0 > N4 > N1 > N3. CINeMA confidence was high for N3 versus N0 and moderate for N4 versus N0. CONCLUSIONS: Gradual bDMARD dose reduction while maintaining background cDMARD as backbone therapy showed the most favourable comparative flare profile, whereas bDMARD discontinuation was associated with a substantially higher flare risk.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.