Objectives The aim of this study was to examine the frequency and reasons of discontinuation of TNF-α inhibitor treatment in rheumatoid arthritis (RA) patients in daily practice. We focused on (serious) infections, (skin) malignancies, (local) allergic reactions, inefficacy and remission. Furthermore, we investigated if the discontinuation was temporarily or permanent, if there were differences between the five TNF-α inhibitors (etanercept, adalimumab, infliximab, golimumab, certolizumab pegol), if there was dose reduction during treatment and if there were differences between men and women.
Methods This is a retrospective cohort study of RA patients treated with TNF-α inhibitors of the Rheumatology department Spaarne Gasthuis in Haarlem between January 2012 until January 2015. The variables of the database were tested with Kaplan Meier, Cox-regression and Chi-square test.
Results In total 274 patients were included of whom 184 (67.2%) used etanercept, 63 (23%) used adalimumab and the groups treated with infliximab, golimumab and certolizumab pegol had each nine patients (3.3%). Of the 274 patients, 93 (33.9%) continued with the same TNF-α inhibitor treatment without interruption. The mean treatment duration in these patients was 30.1 months. Furthermore, 101 patients (36.9%) stopped treatment temporarily, of whom 95 stopped for less than 6 months. The reasons for the temporary stops were mild infections (64), newly diagnosed malignancies (2), local allergic skin reactions (1) and remission (6). Finally the first treatment episode in the study period was stopped permanently in the remaining 80 patients (29.2%), of whom 19 switched to another TNF-α inhibitor, 13 switched to another biological and 48 stopped biological treatment permanently. In table 1 reasons for stopping TNF-α inhibitor treatment are shown. Dose reduction of TNF-α inhibitor treatment was observed in 50 patients (18%), resulting in a relapse of RA in only 5 patients. Etanercept showed significantly more interruptions than the other TNF-α inhibitors. Other differences between the five TNF-α inhibitors and between men and women were not significant.
Conclusions Concluding, 71% of the RA patients stayed on the same TNF-α inhibitor, of whom 34% without interruptions and 37% with mostly short interruptions. This is in line with the literature (1). The remaining 29% of the patients stopped TNF-α inhibitor treatment permanently. Short treatment interruptions were found significantly more in the etanercept group. A plausible explanation for this finding is the higher injection frequency (once per week) of etanercept leading to more frequent interruptions. In conclusion, TNF-α inhibitor treatment in RA patients is safe and effective in more than 70% of the patients. Dose reduction may be an option in some patients, but stopping because of remission is rare and half of the patients flared within six months.
Monaco C, Nanchahal J, Taylor P, Feldmann M. Anti-TNF therapy: past, present and future. International Immunology. 2014;27(1):55–62
Disclosure of Interest None declared
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