Biologic disease-modifying antirheumatic drugs (DMARDs) are genetically engineered to act like natural proteins in the immune system. In this review, the complete withdrawal of biologic therapy in patients with established disease does not conclude in sustained LDA or remission, and the most of patients will encounter a flare of their disease. 

The study aimed to assess the published studies involved dose down and then discontinuation of biologic therapy among rheumatoid arthritis (RA) patients, especially regarding the criteria for such dosing and the influence on clinical events.

The analysis included the RA studies that consecutively reduced the dose and then terminated therapy of one or more biologic disease-modifying antirheumatic drugs (bDMARDs); certolizumab, tocilizumab, adalimumab, rituximab, abatacept, infliximab, etanercept, and golimumab.

A total of five studies were selected with heterogeneous populations of patients with RA. The patients were needed to be in remission or have to acquire low disease activity (LDA) before dose titration. The patients' percentage who successfully reduced and terminated the bDMARD treatment noticed was 25-65%. Although, the flare rate noticed to be greater among patients who continued a standard dose. The down-titration of the bDMARD dose was the only variable that estimated relapse in more than one study.

The down-titration and termination of bDMARD therapy should be undertaken with careful monitoring among the patients who achieved LDA or remission.Although, it is assumed that some patients will flare, but not understood how to detect these patients.