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Extended report
Patients with RA in remission on TNF blockers: when and in whom can TNF blocker therapy be stopped?
  1. Benazir Saleem,
  2. Helen Keen,
  3. Vincent Goeb,
  4. Rekha Parmar,
  5. Sharmin Nizam,
  6. Elizabeth M A Hensor,
  7. Sarah M Churchman,
  8. Mark Quinn,
  9. Richard Wakefield,
  10. Philip G Conaghan,
  11. Frederique Ponchel,
  12. Paul Emery
  1. Leeds Institute of Molecular Medicine, Section of Musculoskeletal Disease, University of Leeds, Leeds, UK
  1. Correspondence to Professor Paul Emery, arc Professor of Rheumatology, Head of Academic Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, Chapel Allerton Hospital, Chapeltown Road, Leeds LS7 4SA, UK; p.emery{at}


Objectives Combination therapy with methotrexate (MTX) and tumour necrosis factor (TNF) blockade has increased remission rates in patients with rheumatoid arthritis. However, there are no guidelines regarding cessation of therapy. There is a need for markers predictive of sustained remission following cessation of TNF blocker therapy.

Methods Patients in remission (DAS28 <2.6) treated with a TNF blocker and MTX as initial or delayed therapy were recruited. Joints were assessed for grey scale synovitis and power Doppler (PD) activity. Immunological assessment involved advanced six-colour flow cytometry.

Results Of the 47 patients recruited, 27 had received initial treatment and 20 delayed treatment with TNF blocking drugs. Two years after stopping TNF blocker therapy, the main predictor of successful cessation was timing of treatment; 59% of patients in the initial treatment group sustained remission compared with 15% in the delayed treatment group (p=0.003). Within the initial treatment group, secondary analysis showed that the only clinical predictor of successful cessation of treatment was shorter symptom duration before receiving treatment (median 5.5 months vs 9 months; p=0.008). No other clinical features were associated with successful cessation of therapy. Thirty-five per cent of patients had low PD activity but levels were not informative. Several immunological parameters were significantly associated with sustained remission including abnormal differentiation subset of T cells and regulatory T cells. Similar non-significant trends were observed in the delayed treatment group.

Conclusion In patients in remission with low levels of imaging synovitis receiving combination treatment with a TNF blocker and MTX, immunological parameters and short duration of untreated symptoms were associated with successful cessation of TNF blocker therapy.

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  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval This study was conducted with the approval of the Leeds Teaching Hospital Trust.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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    BMJ Publishing Group Ltd and European League Against Rheumatism
  • Miscellaneous
    BMJ Publishing Group Ltd and European League Against Rheumatism