Background Non-tumor necrosis factor (TNF) agents, such as tocilizumab (TCZ) and abatacept (ABT), were widely used in the treatment of rheumatoid arthritis (RA). It seems that non-TNF agents are slightly different from anti-TNF agents in respect to dependency on methotrexate (MTX). Although MTX is a very important concomitant drug in anti-TNF therapy, MTX may not be so in non-TNF therapy for majority of patients. MTX have many severe adverse events (AE) such as interstitial pneumonia, severe infection, and myelosuppression. Tapering or stopping of MTX have been tried in our institute to avoid AE of MTX when RA patients treated with non-TNF agents reached at sustained remission. We report the preliminary results of MTX tapering in non-TNF therapy in this study.
Objectives This retrospective study evaluated tapering or stopping of MTX in non-TNF therapy (TCZ and ABT) and impact of it to RA treatment in clinical practice.
Methods 27 RA patients who initiated TCZ or ABT with concomitant MTX and continued non-TNF agents for 2 years were used. Time-course of disease activity (DAS28-CRP and CDAI), arthritis marker (serum MMP-3), activity of daily living (mHAQ), joint destruction (ΔmTSS per a year) and tapering concomitant drug (MTX and prednisolone) were investigated. MTX was tapered depending on physicians decisions and stopped if possible.
Results 20 females and 7 males with mean age of 60 years were used in this study. Mean RA duration was 11.8 years. TCZ was continued for 2 years in 16 cases and ABT in 11 cases. MTX of mean dosage of 9.0mg/week (4.0–16.0 mg/w) was prescribed in all patients at baseline. Mean DAS28-CRP was 4.57 at baseline, 2.26 at 1 year and 2.00 at 2 years. There were significant decreases not only from baseline to 1 years (p<0.0001) but also from 1 year to 2 years (p=0.04). Significant decrease and sustainment were also observed in CDAI, serum MMP-3 and mHAQ) (Fig. 1). Although ΔmTSS at baseline was )10.0, it was significantly improved to 1.5 from baseline to 1 year (p=0.0001) and to 0.5 from 1 year to 2 years (p<0.0001). Mean MTX dosage was significantly decreased from 9.0mg/w at baseline to 4.8mg/w at 1 year (p=0.0003) and to 2.9mg/w at 2 years (p<0.0001). There was a significant difference of MTX dosage between at 1 year and 2 years (p=0.049). Although MTX was concomitant in all patients at baseline, it was used in only 66.7% at 1 year and only 40.7% at 2 year. Mean PSL was also tapered from 3.5mg/day at baseline to 1.2mg/d at 2 years (Fig. 2). Similar trends were observed in both patients treated with TCZ and ABT.
Conclusions This study suggested that concomitant MTX may be tapered or stopped in RA patients treated with TCZ or ABT and reached to sustained remission without worsening disease activity and joint destruction. Information of prospective large studies was necessary in the future.
Disclosure of Interest None declared