PhD defence E. (Elise) van Mulligen

Treatment outcomes in rheumatoid arthritis (RA) have improved enormously in the last decades, resulting in more patients with a well-controlled disease. This has raised the question whether we need to continue or taper treatment. Tapering medication increases the risk of disease flares, which can have a great impact on patients’ lives and on society due to productivity loss. Therefore, it is important to consider these different viewpoints before making a (shared) decision. Moreover, the optimal tapering strategy leading to the least amount of flares has not been developed yet. The aim of this thesis was therefore to study the clinical-, patient-, and the societal perspective of tapering to help rheumatologist and RA patients with their decisions whether they should taper or not.

These perspectives were addressed using data from the TApering strategies in Rheumatoid Arthritis (TARA) trial. The TARA trial was set-up to investigate the best tapering strategy in RA patients with a well-controlled disease. Patients were randomised into gradual tapering either the conventional rheumatic drug in the first year followed by the biological rheumatic drug in the second year, or vice versa.

Up to 9 months, flare rates of tapering the conventional or biological drug were completely similar. After one year, a non-significant 10% difference was found, favoring tapering the conventional drug. After two years, 60% of the patients had a disease flare. In total, 83% of the patients were able to reduce their medication dosages. Following this, we performed a systematic literature review investigating whether completely stopping rheumatic drugs is a feasible treatment outcome for RA. We found that 10%-20% of patients were able to completely stop their medication for longer than one year. We also investigated whether DFR is also an achievable treatment outcome in an established RA population, and it appeared to be achievable in 15% of the patients, and was slightly more frequent in patients who tapered their csDMARD first. Next, the impact of these disease flares on patient’s lives was determined. A flare negatively influenced general health, morning stiffness, functional ability, quality of life, and fatigue and this effect lasted for 6 months. Last, an important reason for tapering treatment is to save costs. Health care costs were lower in the patients who tapered the biological first, while costs due to productivity loss were higher. Overall, tapering either the biological or the conventional drug first was equally cost-effective.

Due to corona, the PhD defences do not take place publicly in the usual way in the Senate Hall or in the Professor Andries Querido Room. The candidates will defend their dissertation either in a small group or online.