Choosing Between Treatment De-escalation and Full Discontinuation Prior to TFR

The approach to discontinuing treatment in patients with deep and sustained molecular remission varies, but a common strategy is to stop therapy completely once the patient has maintained remission for a sufficient duration. Data suggest that patients who remain disease-marker negative for 5 years have a high likelihood of success with treatment cessation, with remission rates around 85%. For these patients without adverse events or complications, full discontinuation is generally recommended. Early attempts to stop treatment—at 2 or 3 years—are less common, though some patients may choose to try earlier based on their personal preference or tolerability issues.

For patients struggling with adverse effects or adherence, a stepwise de-escalation can be employed as an intermediate strategy. This tapering period, usually lasting 6 months to a year, allows patients to adjust to a lower drug dose before fully stopping therapy. While this approach can help manage adverse events and provide a gradual transition, it may not significantly improve the chances of long-term treatment-free remission (TFR). It can, however, help clinicians identify patients who might not sustain remission after complete discontinuation by monitoring their response during the dose reduction phase.

Overall, the decision to stop treatment or taper depends on individual patient factors, goals, and tolerability. Longer treatment duration before stopping is generally associated with better outcomes, and discontinuation should be approached with caution and careful monitoring. De-escalation remains a useful tool, especially for patients experiencing difficulties with full-dose therapy, but is not considered essential for all. Both strategies aim to balance the goal of TFR with maintaining patient quality of life and safety.