Original articleEffect of discontinuing TNFα antagonist therapy in patients with remission of rheumatoid arthritis
Introduction
In patients with rheumatoid arthritis (RA), achieving a remission is now a reasonable treatment objective. Among the major therapeutic breakthroughs that have improved outcomes in RA patients in recent years [1] the most notable is the introduction of tumor necrosis factor α (TNFα) antagonists [2], [3], [4]. The proportion of patients in remission ranges from 7% to 25% with conventional disease-modifying antirheumatic drugs (DMARDs) and from 21% to 49% with a TNFα antagonist and methotrexate in combination [5].
Once a remission is achieved, the need for continued TNFα antagonist therapy must be assessed. The dose can be decreased as a preliminary to complete discontinuation [6]. The effects of discontinuing TNFα antagonist therapy after obtaining a remission are poorly understood. Although remission rates are highest in patients with early-stage disease [1], TNFα antagonist therapy can provide remissions in patients with long-standing RA.
The objectives of this study were to identify risk factors for relapse and to measure the time to relapse after TNFα antagonist discontinuation in patients with established RA who had been in remission for at least 6 months. We also evaluated the response of relapses to resumption of the same TNFα antagonist.
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Patients
Between August 1999 and June 2005, we assessed TNFα antagonist continuation rates in 442 patients with inflammatory joint disease [7], of whom 304 met American College of Rheumatology criteria for RA [8]. We identified patients who were in remission, defined as a Disease Activity Score on 28 joints (DAS28) lower than 2.6 [9] for at least 6 months, without nonsteroidal anti-inflammatory drugs and with or without prednisone in a daily dosage of less than 5 mg as recommended by the French Society
Results
We identified 304 RA patients treated with a TNFα antagonist between August 1999 and June 2005 (Fig. 1). There were 247 females and 57 males with a mean age of 58 years. The first TNFα antagonist was etanercept in 157 patients, infliximab in 104, and adalimumab in 43. Furthermore, 91 patients had been switched to a second TNFα antagonist, which was etanercept in 53 patients, infliximab in 7, and adalimumab in 31.
In September 2006, 28 (9.2%) patients met our criteria for disease remission (DAS28 <
Discussion
Our study has a number of limitations. First, we were able to include only 21 of 28 patients in remission. These 28 patients represented 9.2% of our population of 304 RA patients. Remission rates in patients with established RA treated with TNFα antagonists ranged in earlier studies from 7% [3] to 24% [4]. Second, we discontinued TNFα antagonists only in patients who remained in remission after stopping their nonsteroidal anti-inflammatory drugs and decreasing their daily prednisone dosage to 5
Conflict of interest:
None of the authors has any conflicts of interest to declare.
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