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).

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.