No significant differences when tapering TNF blockers vs csDMARDs

Tapering csDMARDs or anti-TNF showed no significant differences in flare ratios, disease activity, functional ability and quality of life between both tapering strategies in the first 12 months of follow-up.

Anti-TNF tapering over csDMARDs recommended, with care for disease flare and patient wishes

Tapering conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or anti-tumor necrosis factor (TNF) showed no significant differences in flare ratios, disease activity, functional ability and quality of life between both tapering strategies during the first 12 months of follow-up.

Early detection of rheumatoid arthritis (RA), early initiation of ‘intensive’ therapy, and a treat-to-target (T2T) approach have led to substantial improvements in clinical and radiographic outcomes in RA over the last two decades. This has resulted in 50% to 60% of early RA patients achieving sustained remission during the first year of follow-up. Although current guidelines recommend considering tapering treatment, an optimal approach to gradually de-escalate csDMARDs or biologic DMARDs is still lacking.

Van Mulligen et al. aimed to evaluate the effectiveness of two tapering strategies: gradual tapering of csDMARDs and TNF therapy during one year of follow-up. This study was set up as a multicentre, single-blinded, randomized, controlled trial. Eligible patients were adults with RA <10 years (2010 criteria) who were in sustained remission for at least 3 consecutive months, defined as a DAS≤2.4 and a swollen joint count (SJC) ≤1. Treatment was csDMARDs + a TNF blocker. Patients were randomized into gradual tapering csDMARDs followed by the TNF blocker or vice versa. Medication was tapered in three steps over the course of 6 months. Gradual tapering was done by cutting the dosage into a half, a quarter and thereafter it was stopped. The primary outcome for the clinical effectiveness was disease flare defined as DAS44>2.4 and/or SJC>1. Secondary outcomes were quality of life and functional ability. 

A total of 189 patients were randomly assigned to tapering csDMARDs (n=94) or tapering anti-TNF (n=95). The majority of patients were female (71% in the csDMARDs tapering group and 61% in the anti-TNF tapering group) with a mean age of approximately 56 years. No difference in flare ratio was found; the cumulative flare ratio in the csDMARD and anti-TNF tapering group was 35% and 45%, respectively, with the biggest difference between the two groups in the last 3 months. The tapering status at 12 months revealed that 68% of those tapering csDMARDs had completely tapered their medication vs 51% for those tapering anti-TNF. Seven percent of patients tapering csDMARDs was at a quarter of the original dose (vs 20%), and 15% were at half of the original dose (vs 11%). Finally, 9% of csDMARDs tapering patients were (again) at the original dose vs 18% of those on anti-TNF. Furthermore, no difference in DAS was found between the two groups, or in patient-reported outcomes. Based on these outcomes, Van Mulligen pleaded to taper medication in RA patients who are in sustained remission with a preference to taper anti-TNF over csDMARDs but also to take into account the risk of a disease flare and considering the wishes of the patient with regard to therapy (1).

Source:
1. Van Mulligen E, et al. Gradual tapering TNF blockers versus conventional synthetic DMARDs in patients with rheumatoid arthritis in sustained remission: first-year results of the randomized controlled TARA-study. Abstract OP0113. EULAR 2018.

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