Tapering TNF blockers in axSpA and PsA: a successful approach

In both psoriatic arthritis (PsA) and axial spondylarthritis (axSpA), a T2T TNF-blocker tapering strategy showed to be non-inferior to a T2T strategy.

T2T strategy tampering led to substantial decrease in TNF inhibitors use 

Although TNF blockers are safe and effective, high costs and a somewhat increased infection risk are long-term drawbacks. Therefore, tapering in patients that successfully achieved low disease activity or remission in PsA or axSpA might be a valuable approach. Dr Celia Michielsens (Sint Maartenskliniek and Radboud Institute for Health Sciences, the Netherlands) and her team investigated whether a T2T strategy with tapering is non-inferior (with a pre-specified non-inferiority margin of 20%) compared with a T2T strategy without tapering in a randomised, controlled, open-label, non-inferiority trial¹.

All participants used TNF inhibitors and had stable low disease activity for ≥6 months. They were randomised (2:1) to a T2T tapering or no-tapering strategy and followed for 12 months. Low disease activity was defined as a Psoriatic Arthritis Disease Activity Score (PASDAS) ≤3.2 for PsA, and/or Ankylosing Spondylitis Disease Activity Score (ASDAS) <2.1, and/or judgement of physician and patient.

Patients in the tapering group used more of other medications

Of the 81 participants in the tapering group, 52% had PsA and the rest had axSpA. At 12 months, 73% of participants in the non-tapering group and 69% in the tapering group achieved low disease activity. This difference was well below the inferiority margin, thus confirming non-inferiority. At 12 months, 58 (72%) participants of the tapering group were successfully tapered. Patients in the tapering group used more other medications, a difference that was statistically significant regarding NSAID use (54% vs 24%; P=0.002). However, the risk of grade 3/4 infections was 46% lower and the risk of injection site reactions was 23% lower in the tapering compared with the non-tapering group.

Taken together, there was no significant difference between a tapering and a non-tapering approach regarding disease activity. “This might have been because we used not a fixed but an individualised tapering approach,” Dr Michielsen said. Moreover, tapering led to a substantial reduction in TNF inhibitor use.

Reference:
1. Michielsens C, et al. Treat-to-target dose reduction and withdrawal strategy of TNF inhibitors in psoriatic arthritis and axial spondyloarthritis: a randomized controlled non-inferiority trial. OP0261, EULAR 2022, 1–4 June, Copenhagen, Denmark.