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Gul H, Di Matteo A, Anioke I, Shuweidhi F, Mankia K, Ponchel F, Emery P. Predicting Flare in Patients With Rheumatoid Arthritis in Biologic Induced Remission, on Tapering, and on Stable Therapy. ACR Open Rheumatol 2024; 6:294-303. [PMID: 38411023 PMCID: PMC11089437 DOI: 10.1002/acr2.11656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 01/02/2024] [Accepted: 01/11/2024] [Indexed: 02/28/2024] Open
Abstract
OBJECTIVE The tapering of biologic disease-modifying antirheumatic drug (b-DMARD) therapy for patients with rheumatoid arthritis (RA) in stable remission is frequently undertaken, but specific guidance on how to successfully taper is lacking. The objective of this study is to identify predictors of flare in patients in stable b-DMARD-induced clinical remission, who did or did not follow structured b-DMARD tapering. METHODS Patients with RA receiving b-DMARD treatment who had achieved sustained remission according to a Disease Activity Score in 28 joints using the C-reactive protein level (DAS28-CRP) <2.6 for ≥6 months were offered tapering. Clinical, ultrasound (US) (total power Doppler [PD]/grayscale abnormalities), CD4+ T cell subsets, and patient-reported outcomes (PROs) were collected at inclusion. The primary endpoint was the occurrence of flare (loss of DAS28-CRP remission) over 12 months. Logistic regression analyses identified predictors of flare. Dichotomization into high/low-risk groups was based on 80% specificity using the area under the receiving operator curve (AUROC). RESULTS Of 63 patients choosing tapering, 23 (37%) flared compared with 12 of 60 (20%) on stable treatment (P = 0.043). All patients who flared regained remission upon reinstating treatment. In the tapering group, flare was associated with lower regulatory T cell (Treg) (P < 0.0001) and higher CRP levels (P < 0.0001), erythrocyte sedimentation rate (P < 0.035), and inflammation-related cells (IRCs) (P = 0.054); stepwise modeling selected Tregs (odds ratio [OR] = 0.350, P = 0.004), IRCs (OR = 1.871, P = 0.007), and CRP level (OR = 1.577, P = 0.004) with 81.7% accuracy and AUROC = 0.890. In the continued therapy group, modeling retained the tender joint count, total PD, and visual analog scale pain score, with 82.1% accuracy and AUROC = 0.899. Most patients in the study were considered low risk of flare (80 of 123 patients [65%]). Only 5 of 37 (13.5%) of the low-risk patients who tapered flared, which was notable compared with the continued therapy group (20% flare). CONCLUSION Flare on tapering b-DMARDs was predicted by lower Tregs and elevated inflammation biomarkers (IRCs/CRP level); flare on continued b-DMARDs was associated with raised pain parameters and US inflammation. Knowledge of these biomarkers should improve outcomes by targeted selection for tapering, and by increased monitoring of those on continued therapy predicted to flare.
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Affiliation(s)
| | - Andrea Di Matteo
- University of Leeds and National Institute for Health and Care Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS TrustLeedsUK
| | | | | | - Kulveer Mankia
- University of Leeds and National Institute for Health and Care Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS TrustLeedsUK
| | | | - Paul Emery
- University of Leeds and National Institute for Health and Care Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS TrustLeedsUK
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Ward MM, Madanchi N, Yazdanyar A, Shah NR, Constantinescu F. Prevalence and predictors of sustained remission/low disease activity after discontinuation of induction or maintenance treatment with tumor necrosis factor inhibitors in rheumatoid arthritis: a systematic and scoping review. Arthritis Res Ther 2023; 25:222. [PMID: 37986101 PMCID: PMC10659063 DOI: 10.1186/s13075-023-03199-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND To determine the prevalence of sustained remission/low disease activity (LDA) in patients with rheumatoid arthritis (RA) after discontinuation of tumor necrosis factor inhibitors (TNFi), separately in induction treatment and maintenance treatment studies, and to identify predictors of successful discontinuation. METHODS We performed a systematic literature review of studies published from 2005 to May 2022 that reported outcomes after TNFi discontinuation among patients in remission/LDA. We computed prevalences of successful discontinuation by induction or maintenance treatment, remission criterion, and follow-up time. We performed a scoping review of predictors of successful discontinuation. RESULTS Twenty-two induction-withdrawal studies were identified. In pooled analyses, 58% (95% confidence interval (CI) 45, 70) had DAS28 < 3.2 (9 studies), 52% (95% CI 35, 69) had DAS28 < 2.6 (9 studies), and 40% (95% CI 18, 64) had SDAI ≤ 3.3 (4 studies) at 37-52 weeks after discontinuation. Among patients who continued TNFi, 62 to 85% maintained remission. Twenty-two studies of maintenance treatment discontinuation were also identified. At 37-52 weeks after TNFi discontinuation, 48% (95% CI 38, 59) had DAS28 < 3.2 (10 studies), and 47% (95% CI 33, 62) had DAS28 < 2.6 (6 studies). Heterogeneity among studies was high. Data on predictors in induction-withdrawal studies were limited. In both treatment scenarios, longer duration of RA was most consistently associated with less successful discontinuation. CONCLUSIONS Approximately one-half of patients with RA remain in remission/LDA for up to 1 year after TNFi discontinuation, with slightly higher proportions in induction-withdrawal settings than with maintenance treatment discontinuation.
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Affiliation(s)
- Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Building 10CRC, Room 4-1339, 10 Center Drive, Bethesda, MD, 20892-1468, USA.
| | - Nima Madanchi
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
- Current address: Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ali Yazdanyar
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA, USA
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
- Current address: Division of Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nehal R Shah
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
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Shin K, Kwon HM, Kim MJ, Yoon MJ, Chai HG, Kang SW, Park W, Park SH, Suh CH, Kim HA, Lee SG, Lee CK, Bae SC, Park YB, Song YW. Two-year clinical outcomes after discontinuation of long-term golimumab therapy in Korean patients with rheumatoid arthritis. Korean J Intern Med 2022; 37:1061-1069. [PMID: 34883551 PMCID: PMC9449209 DOI: 10.3904/kjim.2021.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/15/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to investigate long-term post-discontinuation outcomes in patients with rheumatoid arthritis (RA) who had been treated with tumor necrosis factor-α inhibitors (TNF-αi) which was then discontinued. METHODS Sixty Korean patients with RA who participated in a 5-year GO-BEFORE and GO-FORWARD extension trials were included in this retrospective study. Golimumab was deliberately discontinued after the extension study (baseline). Patients were then followed by their rheumatologists. We reviewed their medical records for 2 years (max 28 months) following golimumab discontinuation. Patients were divided into a maintained benefit (MB) group and a loss-of-benefit (LB) group based on treatment pattern after golimumab discontinuation. The LB group included patients whose conventional disease-modifying antirheumatic drug(s) were stepped-up or added/switched (SC) and those who restarted biologic therapy (RB). RESULTS The mean age of patients at baseline was 56.5 years and 55 (91.7%) were females. At the end of follow-up, 23 (38.3%) patients remained in the MB group. In the LB group, 75.7% and 24.3% were assigned into SC and RB subgroups, respectively. Fifty percent of patients lost MB after 23.3 months. Demographics and clinical variables at baseline were comparable between MB and LB groups except for age, C-reactive protein level, and corticosteroid use. Restarting biologic therapy was associated with swollen joint count (adjusted hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.01 to 3.55) and disease duration (adjusted HR, 1.12; 95% CI, 1.02 to 1.23) at baseline. CONCLUSION Treatment strategies after discontinuing TNF-αi are needed to better maintain disease control and quality of life of patients with RA.
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Affiliation(s)
- Kichul Shin
- Division of Rheumatology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul,
Korea
| | - Hyun Mi Kwon
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Min Jung Kim
- Division of Rheumatology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul,
Korea
| | - Myung Jae Yoon
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Hyun Gyung Chai
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Seong-Wook Kang
- Division of Rheumatology, Chungnam National University Hospital, Daejeon,
Korea
| | - Won Park
- Division of Rheumatology, Inha University Hospital, Incheon,
Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Chang Hee Suh
- Division of Rheumatology, Ajou University Hospital, Suwon,
Korea
| | - Hyun Ah Kim
- Division of Rheumatology, Hallym University Sacred Heart Hospital, Anyang,
Korea
| | - Seung-Geun Lee
- Division of Rheumatology, Pusan National University Hospital, Busan,
Korea
| | - Choong Ki Lee
- Division of Rheumatology, Yeungnam University Medical Center, Daegu,
Korea
| | - Sang-Cheol Bae
- Division of Rheumatology, Hanyang University Seoul Hospital, Seoul,
Korea
| | - Yong-Beom Park
- Division of Rheumatology, Severance Hospital, Yonsei University College of Medicine, Seoul,
Korea
| | - Yeong Wook Song
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, and College of Medicine, Medical Research Center, Seoul National University, Seoul,
Korea
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Birkner B, Rech J, Edelmann E, Verheyen F, Schett G, Stargardt T. Patient-individual tapering of DMARDs in rheumatoid arthritis patients in a real-world setting. Rheumatology (Oxford) 2022; 62:1476-1484. [PMID: 35980267 DOI: 10.1093/rheumatology/keac472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 07/17/2022] [Accepted: 07/17/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We aim to provide real-world evidence on the effectiveness of patient-individual tapering of DMARDs for patients with rheumatoid arthritis (RA) in daily clinical practice using medical records and claims data. METHODS We utilize data obtained through a controlled prospective cohort study in Germany conducted from July 2018 to March 2021. Participants consist of RA patients in sustained remission (>6 months) who were eligible for tapering at enrolment. Patients treated with individual tapering based on shared decision making (n = 200) are compared with patients without any dose-reduction (n = 237). The risk of loss of remission and the risk of flare is assessed with risk-adjusted Kaplan-Meier estimators and Cox-Regressions. We evaluate differences in costs one year before and after baseline based on claims data for the subgroup of patients insured at one major sickness fund in Germany (n = 76). RESULTS The risk of flare (HR 0.88 95%-CI: 0.59-1.30) or loss of remission (HR 1.04 95%-CI: 0.73, 1.49) was not statistically different between the individual tapering group and the continuation group. Minor increases of disease activity and decreases of quality of life were observed 12 months after baseline, again with no statistically significant difference. Drug costs decreased by 1,017€in the individual tapering group while increased by 1,151€in the continuation group (p< 0.01). CONCLUSION Individual tapering of DMARDs does not increase the average risk of experiencing flares or loss of remission. Encouraging rheumatologists and patients to apply tapering in shared decision may be a feasible approach to allow individualisation of treatment in RA.
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Affiliation(s)
- Benjamin Birkner
- Hamburg Center for Health Economics (HCHE), Universität Hamburg, Hamburg, Germany
| | - Jürgen Rech
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
| | | | | | - Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Tom Stargardt
- Hamburg Center for Health Economics (HCHE), Universität Hamburg, Hamburg, Germany
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Mori S, Okada A, Koga T, Ueki Y. Long-term outcomes after discontinuing biological drugs and tofacitinib in patients with rheumatoid arthritis: A prospective cohort study. PLoS One 2022; 17:e0270391. [PMID: 35737642 PMCID: PMC9223309 DOI: 10.1371/journal.pone.0270391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/09/2022] [Indexed: 11/30/2022] Open
Abstract
Objective This study examined long-term outcomes of biological disease-modifying antirheumatic drugs (bDMARDs) and tofacitinib discontinuation in patients with rheumatoid arthritis (RA). Methods Ninety-seven RA patients who desired drug discontinuation after sustained remission or low disease activity for at least 48 weeks due to stable treatment with biological drugs or tofacitinib were enrolled into this study. All patients were prospectively followed until disease flare or the end of the study. Discontinued drugs (previous drugs) were reintroduced to treat flares. Results Following bDMARD/tofacitinib discontinuation (mean follow-up, 2.1 years; standard deviation, 2.0), disease flare occurred at a crude incidence rate of 0.36 per person-year. The median time to flare was 1.6 years (95% confidence interval [CI] 0.9–2.6), and the cumulative flare probability was estimated to be 45% at 1 year, 64% at 3 years, and 80% at 5 years. No or little radiological progression was shown in 87.1% of patients who maintained remission for 3 years. A Fine‒Gray competing risk regression analysis showed that predictive factors for a flare were longer RA duration at the start of bDMARD/tofacitinib treatment, previous failure of treatment with bDMARDs, and a shorter period of remission or low disease activity before drug discontinuation. Type of discontinued drug was not identified as a predictive factor after adjusting for other predictor variables. Restarting previous treatment regimens led to rapidly regaining disease control in 89% of flare patients within 1 month. Conclusion Discontinuation of bDMARD/tofacitinib may be a feasible strategy in RA patients, especially patients with early treated and longer-controlled RA. Flares are manageable in most RA patients and radiological progression is rare for at least 3 years in patients with sustained remission after bDMARD/tofacitinib discontinuation.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, National Hospital Organization Kumamoto Saishun Medical Center, Kohshi, Kumamoto, Japan
- * E-mail:
| | - Akitomo Okada
- Department of Rheumatology, Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan
| | - Tomohiro Koga
- Division of Advanced Preventive Medical Sciences, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Center for Bioinformatics and Molecular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yukitaka Ueki
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Sasebo, Nagasaki, Japan
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Defining the Optimal Strategies for Achieving Drug-Free Remission in Rheumatoid Arthritis: A Narrative Review. Healthcare (Basel) 2021; 9:healthcare9121726. [PMID: 34946453 PMCID: PMC8701994 DOI: 10.3390/healthcare9121726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022] Open
Abstract
Background: It is now accepted that the optimum treatment goal for rheumatoid arthritis (RA) is sustained remission, as this has been shown to be associated with the best patient outcomes. There is little guidance on how to manage patients once remission is achieved; however, it is recommended that patients can taper therapy, with a view to discontinuing and achieving drug-free remission if treatment goals are maintained. This narrative review aims to present the current literature on drug-free remission in rheumatoid arthritis, with a view to identifying which strategies are best for disease-modifying anti-rheumatic drug (DMARD) tapering and to highlight areas of unmet clinical need. Methods: We performed a narrative review of the literature, which included research articles, meta-analyses and review papers. The key search terms included were rheumatoid arthritis, remission, drug-free remission, b-DMARDS/biologics, cs-DMARDS and tapering. The databases that were searched included PubMed and Google Scholar. For each article, the reference section of the paper was reviewed to find additional relevant articles. Results: It has been demonstrated that DFR is possible in a proportion of RA patients achieving clinically defined remission (both on cs and b-DMARDS). Immunological, imaging and clinical associations with/predictors of DFR have all been identified, including the presence of autoantibodies, absence of Power Doppler (PD) signal on ultrasound (US), lower disease activity according to composite scores of disease activity and lower patient-reported outcome scores (PROs) at treatment cessation. Conclusions: DFR in RA may be an achievable goal in certain patients. This carries importance in reducing medication-induced side-effects and potential toxicity, the burden of taking treatment if not required and cost effectiveness, specifically for biologic therapy. Prospective studies of objective biomarkers will help facilitate the prediction of successful treatment discontinuation.
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Ochiai M, Tanaka E, Sato E, Inoue E, Abe M, Saka K, Sugano E, Sugitani N, Higuchi Y, Yamaguchi R, Sugimoto N, Ikari K, Nakajima A, Yamanaka H, Harigai M. Successful discontinuation of biological disease-modifying antirheumatic drugs in patients with rheumatoid arthritis in real-world settings. Mod Rheumatol 2021; 31:790-795. [PMID: 33538611 DOI: 10.1080/14397595.2021.1883252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To analyze the proportion of successful biological disease-modifying antirheumatic drugs (bDMARDs) discontinuation and related factors in patients with rheumatoid arthritis (RA) in clinical settings. METHODS Among 1775 RA patients who started bDMARDs between 2003 and 2012, 43 patients with DAS28-ESR <3.2 at the time of bDMARD discontinuation were extracted. Patients were divided into two groups (bio-free success: BS and bio-free failure: BF groups) based on bDMARD usage and disease activity 1 year after discontinuation. We evaluated the proportion of bio-free success and assessed factors related to bio-free success. RESULTS Twenty-five patients (58.1%: BS group) maintained discontinuation of bDMARDs and DAS28-ESR <3.2 at 1 year after discontinuation. The median DAS28-ESR at bDMARD initiation was lower in the BS group than in the BF group (3.95 vs 5.04; p = .04). The BS group experienced a larger decrease in average glucocorticoid (GC) dose during bDMARD use than the BF group (-3.0 mg/day vs 0 mg/day; p = .01). CONCLUSION bDMARDs were discontinued without flare up of RA in 58.1% of patients with RA in clinical settings. A lower DAS28-ESR at initiation and reduction of GC dose before discontinuation of bDMARD were important factors associated with bio-free success.
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Affiliation(s)
- Moeko Ochiai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eiichi Tanaka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eri Sato
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Keyaki Total Clinic, Chiba, Japan
| | - Eisuke Inoue
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Research Administration Center, Showa University, Tokyo, Japan
| | - Mai Abe
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Kumiko Saka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eri Sugano
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Naohiro Sugitani
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yoko Higuchi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Rei Yamaguchi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Naoki Sugimoto
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Katsunori Ikari
- Department of Orthopedics, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Ayako Nakajima
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Center for Rheumatic Diseases, Mie University Hospital, Mie, Japan
| | - Hisashi Yamanaka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Rheumatology, Sanno Medical Center, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Naniwa T, Iwagaitsu S, Kajiura M. Successful cessation of tumor necrosis factor inhibitor treatment in rheumatoid arthritis patients and potential predictors for early flare: An observational study in routine clinical care. Mod Rheumatol 2020; 30:948-958. [DOI: 10.1080/14397595.2019.1702253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Taio Naniwa
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, and Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
- Takeuchi Orthopedics & Internal Medicine, Chita, Japan
| | - Shiho Iwagaitsu
- Department of Nephrology and Rheumatology, Aichi Medical University School of Medicine, Nagakute, Japan
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Schlager L, Loiskandl M, Aletaha D, Radner H. Predictors of successful discontinuation of biologic and targeted synthetic DMARDs in patients with rheumatoid arthritis in remission or low disease activity: a systematic literature review. Rheumatology (Oxford) 2020; 59:324-334. [PMID: 31325305 DOI: 10.1093/rheumatology/kez278] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 05/29/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To systematically review possible predictors of successful discontinuation of biologic or targeted synthetic DMARDs (b/tsDMARDs) in RA patients in remission or low disease activity. METHODS MEDLINE database and Cochrane Library were scanned for studies that discontinued b/tsDMARDs in remission/low disease activity and searched for predictors of successful discontinuation. Additionally, EULAR and ACR meeting abstracts were hand searched. RESULTS Thirty-four studies with a total of 5724 patients were included. Predictors of successful b/tsDMARD discontinuation were (number of studies): low disease activity (n = 13), better physical function (n = 6), low or absence of rheumatoid factor (n = 5) or ACPA (n = 3), low levels of CRP (n = 3) or ESR (n = 3), shorter disease duration (n = 3), low signals of disease activity by ultrasound (n = 3). Only one study with high risk of bias was identified on tsDMARD discontinuation. CONCLUSION Several predictors of successful bDMARD discontinuation were identified. Although studies are heterogeneous, these predictors may inform clinical decision making in patients who are considered for a potential bDMARD discontinuation.
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Affiliation(s)
- Lukas Schlager
- Division of Rheumatology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
| | - Michaela Loiskandl
- Division of Rheumatology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
| | - Helga Radner
- Division of Rheumatology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
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10
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Cavalli G, Favalli EG. Biologic discontinuation strategies and outcomes in patients with rheumatoid arthritis. Expert Rev Clin Immunol 2019; 15:1313-1322. [PMID: 31663390 DOI: 10.1080/1744666x.2020.1686976] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease, which affects joints as well as extra-articular tissues. In the last decades, increasing targeted therapeutic options dramatically improved RA management by doubling the rate of patients achieving clinical remission. Currently, there is a need for management strategies aimed at limiting treatment-related adverse events and costs in good responders.Areas covered: Data on de-escalation of biologic drugs (especially for anti-TNF agents) are mainly available from post-hoc analyses of randomized controlled trials and from registry-based observational studies. This narrative review illustrates the rationales for dose tapering and expands to provide an overview of the efficacy of the different available strategies for reducing the exposure to biologic drugs in patients achieving a sustained clinical response. Selected studies are discussed as illustrative examples.Expert opinion: Withdrawal of biologic therapy might be attempted in limited patients with very early RA; conversely, established RA is more suitably managed with a progressive decrease of drug regimen, by either dose reduction or injection/infusion spacing. Further studies investigating potential factors predicting post-tapering disease relapse are warranted, in order to better identify the best candidates for a decreased-dose approach.
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Affiliation(s)
- Giulio Cavalli
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), Vita-Salute San Raffaele University and IRCCS San Raffaele Hospital, Milan, Italy
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11
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Kim B, Maverakis E, Raychaudhuri SP. Is It Possible to Discontinue Tumor Necrosis Factor Antagonists after Psoriasis Remission? Ann Dermatol 2019; 31:495-501. [PMID: 33911640 PMCID: PMC7992562 DOI: 10.5021/ad.2019.31.5.495] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/18/2019] [Indexed: 11/30/2022] Open
Abstract
Tumor necrosis factor (TNF) antagonists are highly effective treatments for psoriasis. These agents provide the opportunity to improve disease activity and achieve clinical remission. Despite its efficacy, long-term use of biologics is associated with high financial costs and possibly life-threatening adverse events. Recently, there has been an increasing interest in discontinuing TNF antagonists in patients with psoriasis who have achieved a positive clinical response. However, there is a paucity of data and clinical guidelines concerning the cessation TNF antagonists in psoriasis treatment. Several factors, including cost, subsequent treatment efficacy, relative risks, and tolerability, should be considered before the decision is made to discontinue TNF antagonists. Well-designed clinical trials are necessary to identify factors that may trigger disease exacerbation after medication discontinuation in order to recognize the potential disadvantages of discontinuing treatment in patients who are previously successfully managed on TNF antagonists.
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Affiliation(s)
- Byungsoo Kim
- Department of Dermatology, Pusan National University School of Medicine, Yangsan, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Emanual Maverakis
- Department of Dermatology, School of Medicine, University of California Davis, Sacramento, CA, USA
| | - Siba P Raychaudhuri
- Division of Rheumatology and Immunology, Veterans Affairs Medical Center Sacramento, Sacramento, CA, USA.,Division of Rheumatology, Allergy and Clinical Immunology, Department of Internal Medicine, School of Medicine, University of California Davis, Sacramento, CA, USA
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Keystone EC, Rampakakis E, Movahedi M, Cesta A, Stutz M, Sampalis JS, Nantel F, Maslova K, Bombardier C. Toward Defining Primary and Secondary Nonresponse in Rheumatoid Arthritis Patients Treated with Anti-TNF: Results from the BioTRAC and OBRI Registries. J Rheumatol 2019; 47:510-517. [PMID: 31263067 DOI: 10.3899/jrheum.190102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Although most patients with rheumatoid arthritis (RA) respond to anti-tumor necrosis factor (anti-TNF) treatment, some present with initial nonresponse (1ry nonresponse) or lose initial responsiveness (2ry nonresponse). We compared the rate of real-world "nonresponse" to first anti-TNF as reported by treating physicians to the nonresponse rate per accepted definitions and recommended treat-to-target strategies. METHODS Patients were included from the Biologic Treatment Registry Across Canada (BioTRAC) and Ontario Best Practices Research Initiative (OBRI) registries who were taking their first anti-TNF, with ≥ 1 followup visit. Posthoc reclassification of physician-reported nonresponse was based on prior achievement of 28-joint count Disease Activity Score based on erythrocyte sedimentation rate (DAS28-ESR) low disease activity (LDA), Clinical Disease Activity Index (CDAI) LDA, or good/moderate European League Against Rheumatism (EULAR) response, and actual time of physician-reported nonresponse. RESULTS Among 736 BioTRAC and 640 OBRI patients, 13.7% and 18%, respectively, discontinued their anti-TNF because of physician-reported nonresponse. Based on reclassification using disease activity, 65.6% (BioTRAC) and 87.2% (OBRI) of 1ry nonresponders did not achieve DAS28-ESR LDA, 65.6%/90.7% CDAI LDA, and 46.9%/61.5% good/moderate EULAR response. Among 2ry nonresponders, 50.7%/47.8% did not achieve DAS28-ESR LDA, 37.7%/52.9% CDAI LDA, and 15.9%/19.6% good/moderate EULAR response before treatment discontinuation. Regarding actual time of nonresponse, 18.8% of BioTRAC and 60.8% of OBRI 1ry nonresponders discontinued at ≤ 6 months. In both registries, a high proportion of 2ry nonresponders discontinued their anti-TNF after 12 months (87.0% BioTRAC, 60.9% OBRI). CONCLUSION Physician-reported 1ry nonresponse was more correlated with non-achievement of DAS28-ESR LDA or CDAI LDA, whereas 2ry nonresponse with actual time of discontinuation. Further work is needed to confirm the importance of response and type of response to the initial anti-TNF in identifying patients most likely to benefit from a second biologic agent treatment.
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Affiliation(s)
- Edward C Keystone
- From The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; Toronto General Hospital Research Institute, University Health Network; Janssen Inc.; University of Toronto, Department of Medicine (DMO) and Institute of Health Policy, Management, and Evaluation (IHPME); Mount Sinai Hospital, Division of Rheumatology, Toronto, Ontario; JSS Medical Research Inc., Montreal, Quebec, Canada. .,E.C. Keystone, MD, The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; E. Rampakakis, PhD, JSS Medical Research Inc.; M. Movahedi, MD, PhD, Toronto General Hospital Research Institute, University Health Network; A. Cesta, MSc, Toronto General Hospital Research Institute, University Health Network; M. Stutz, MSc, JSS Medical Research Inc.; J.S. Sampalis, PhD, JSS Medical Research Inc.; F. Nantel, PhD, Janssen Inc.; K. Maslova, PhD, Janssen Inc.; C. Bombardier, MD, Toronto General Hospital Research Institute, University Health Network, and University of Toronto, DMO and IHPME, and Mount Sinai Hospital, Division of Rheumatology.
| | - Emmanouil Rampakakis
- From The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; Toronto General Hospital Research Institute, University Health Network; Janssen Inc.; University of Toronto, Department of Medicine (DMO) and Institute of Health Policy, Management, and Evaluation (IHPME); Mount Sinai Hospital, Division of Rheumatology, Toronto, Ontario; JSS Medical Research Inc., Montreal, Quebec, Canada.,E.C. Keystone, MD, The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; E. Rampakakis, PhD, JSS Medical Research Inc.; M. Movahedi, MD, PhD, Toronto General Hospital Research Institute, University Health Network; A. Cesta, MSc, Toronto General Hospital Research Institute, University Health Network; M. Stutz, MSc, JSS Medical Research Inc.; J.S. Sampalis, PhD, JSS Medical Research Inc.; F. Nantel, PhD, Janssen Inc.; K. Maslova, PhD, Janssen Inc.; C. Bombardier, MD, Toronto General Hospital Research Institute, University Health Network, and University of Toronto, DMO and IHPME, and Mount Sinai Hospital, Division of Rheumatology
| | - Mohammad Movahedi
- From The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; Toronto General Hospital Research Institute, University Health Network; Janssen Inc.; University of Toronto, Department of Medicine (DMO) and Institute of Health Policy, Management, and Evaluation (IHPME); Mount Sinai Hospital, Division of Rheumatology, Toronto, Ontario; JSS Medical Research Inc., Montreal, Quebec, Canada.,E.C. Keystone, MD, The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; E. Rampakakis, PhD, JSS Medical Research Inc.; M. Movahedi, MD, PhD, Toronto General Hospital Research Institute, University Health Network; A. Cesta, MSc, Toronto General Hospital Research Institute, University Health Network; M. Stutz, MSc, JSS Medical Research Inc.; J.S. Sampalis, PhD, JSS Medical Research Inc.; F. Nantel, PhD, Janssen Inc.; K. Maslova, PhD, Janssen Inc.; C. Bombardier, MD, Toronto General Hospital Research Institute, University Health Network, and University of Toronto, DMO and IHPME, and Mount Sinai Hospital, Division of Rheumatology
| | - Angela Cesta
- From The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; Toronto General Hospital Research Institute, University Health Network; Janssen Inc.; University of Toronto, Department of Medicine (DMO) and Institute of Health Policy, Management, and Evaluation (IHPME); Mount Sinai Hospital, Division of Rheumatology, Toronto, Ontario; JSS Medical Research Inc., Montreal, Quebec, Canada.,E.C. Keystone, MD, The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; E. Rampakakis, PhD, JSS Medical Research Inc.; M. Movahedi, MD, PhD, Toronto General Hospital Research Institute, University Health Network; A. Cesta, MSc, Toronto General Hospital Research Institute, University Health Network; M. Stutz, MSc, JSS Medical Research Inc.; J.S. Sampalis, PhD, JSS Medical Research Inc.; F. Nantel, PhD, Janssen Inc.; K. Maslova, PhD, Janssen Inc.; C. Bombardier, MD, Toronto General Hospital Research Institute, University Health Network, and University of Toronto, DMO and IHPME, and Mount Sinai Hospital, Division of Rheumatology
| | - Melissa Stutz
- From The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; Toronto General Hospital Research Institute, University Health Network; Janssen Inc.; University of Toronto, Department of Medicine (DMO) and Institute of Health Policy, Management, and Evaluation (IHPME); Mount Sinai Hospital, Division of Rheumatology, Toronto, Ontario; JSS Medical Research Inc., Montreal, Quebec, Canada.,E.C. Keystone, MD, The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; E. Rampakakis, PhD, JSS Medical Research Inc.; M. Movahedi, MD, PhD, Toronto General Hospital Research Institute, University Health Network; A. Cesta, MSc, Toronto General Hospital Research Institute, University Health Network; M. Stutz, MSc, JSS Medical Research Inc.; J.S. Sampalis, PhD, JSS Medical Research Inc.; F. Nantel, PhD, Janssen Inc.; K. Maslova, PhD, Janssen Inc.; C. Bombardier, MD, Toronto General Hospital Research Institute, University Health Network, and University of Toronto, DMO and IHPME, and Mount Sinai Hospital, Division of Rheumatology
| | - John S Sampalis
- From The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; Toronto General Hospital Research Institute, University Health Network; Janssen Inc.; University of Toronto, Department of Medicine (DMO) and Institute of Health Policy, Management, and Evaluation (IHPME); Mount Sinai Hospital, Division of Rheumatology, Toronto, Ontario; JSS Medical Research Inc., Montreal, Quebec, Canada.,E.C. Keystone, MD, The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; E. Rampakakis, PhD, JSS Medical Research Inc.; M. Movahedi, MD, PhD, Toronto General Hospital Research Institute, University Health Network; A. Cesta, MSc, Toronto General Hospital Research Institute, University Health Network; M. Stutz, MSc, JSS Medical Research Inc.; J.S. Sampalis, PhD, JSS Medical Research Inc.; F. Nantel, PhD, Janssen Inc.; K. Maslova, PhD, Janssen Inc.; C. Bombardier, MD, Toronto General Hospital Research Institute, University Health Network, and University of Toronto, DMO and IHPME, and Mount Sinai Hospital, Division of Rheumatology
| | - Francois Nantel
- From The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; Toronto General Hospital Research Institute, University Health Network; Janssen Inc.; University of Toronto, Department of Medicine (DMO) and Institute of Health Policy, Management, and Evaluation (IHPME); Mount Sinai Hospital, Division of Rheumatology, Toronto, Ontario; JSS Medical Research Inc., Montreal, Quebec, Canada.,E.C. Keystone, MD, The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; E. Rampakakis, PhD, JSS Medical Research Inc.; M. Movahedi, MD, PhD, Toronto General Hospital Research Institute, University Health Network; A. Cesta, MSc, Toronto General Hospital Research Institute, University Health Network; M. Stutz, MSc, JSS Medical Research Inc.; J.S. Sampalis, PhD, JSS Medical Research Inc.; F. Nantel, PhD, Janssen Inc.; K. Maslova, PhD, Janssen Inc.; C. Bombardier, MD, Toronto General Hospital Research Institute, University Health Network, and University of Toronto, DMO and IHPME, and Mount Sinai Hospital, Division of Rheumatology
| | - Karina Maslova
- From The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; Toronto General Hospital Research Institute, University Health Network; Janssen Inc.; University of Toronto, Department of Medicine (DMO) and Institute of Health Policy, Management, and Evaluation (IHPME); Mount Sinai Hospital, Division of Rheumatology, Toronto, Ontario; JSS Medical Research Inc., Montreal, Quebec, Canada.,E.C. Keystone, MD, The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; E. Rampakakis, PhD, JSS Medical Research Inc.; M. Movahedi, MD, PhD, Toronto General Hospital Research Institute, University Health Network; A. Cesta, MSc, Toronto General Hospital Research Institute, University Health Network; M. Stutz, MSc, JSS Medical Research Inc.; J.S. Sampalis, PhD, JSS Medical Research Inc.; F. Nantel, PhD, Janssen Inc.; K. Maslova, PhD, Janssen Inc.; C. Bombardier, MD, Toronto General Hospital Research Institute, University Health Network, and University of Toronto, DMO and IHPME, and Mount Sinai Hospital, Division of Rheumatology
| | - Claire Bombardier
- From The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; Toronto General Hospital Research Institute, University Health Network; Janssen Inc.; University of Toronto, Department of Medicine (DMO) and Institute of Health Policy, Management, and Evaluation (IHPME); Mount Sinai Hospital, Division of Rheumatology, Toronto, Ontario; JSS Medical Research Inc., Montreal, Quebec, Canada.,E.C. Keystone, MD, The Rebecca MacDonald Centre for Arthritis, Mount Sinai Hospital; E. Rampakakis, PhD, JSS Medical Research Inc.; M. Movahedi, MD, PhD, Toronto General Hospital Research Institute, University Health Network; A. Cesta, MSc, Toronto General Hospital Research Institute, University Health Network; M. Stutz, MSc, JSS Medical Research Inc.; J.S. Sampalis, PhD, JSS Medical Research Inc.; F. Nantel, PhD, Janssen Inc.; K. Maslova, PhD, Janssen Inc.; C. Bombardier, MD, Toronto General Hospital Research Institute, University Health Network, and University of Toronto, DMO and IHPME, and Mount Sinai Hospital, Division of Rheumatology
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Predictors of biologic-free disease control in patients with rheumatoid arthritis after stopping tumor necrosis factor inhibitor treatment. BMC Rheumatol 2019; 3:3. [PMID: 31225430 PMCID: PMC6567570 DOI: 10.1186/s41927-019-0071-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 05/31/2019] [Indexed: 02/08/2023] Open
Abstract
Background The aim of this study was to identify predictors of prolonged disease control after discontinuation of tumor necrosis factor inhibitor (TNFi) treatment in patients with rheumatoid arthritis (RA). Methods Post-hoc analysis of 439 RA patients (67.3% rheumatoid factor positive) with longstanding RA in remission or with stable low disease activity, randomized to stopping TNFi treatment in the multicenter POET trial. Prolonged acceptable disease control was defined as not restarting TNFi treatment within 12 months after stopping. Baseline demographic and disease-related variables were included in univariate and multivariate logistic regression analysis for identifying predictors of relapse. Results One year after baseline, 220 patients (50.1%) had not restarted TNFi treatment. Use of an anti-TNF monoclonal antibody (versus a receptor antagonist, OR = 2.41; 95% CI: 1.58–3.67), ≤10 yrs. disease duration (OR = 2.15; 95% CI: 1.42–3.26) and low or moderate multi-biomarker disease activity (MBDA) scores (OR = 2.00; 95% CI: 1.10–3.64) at baseline were independently predictive of successful TNFi discontinuation (area under the receiver operating characteristic curve = 0.66; 95% CI: 0.61–0.71). Results were similar when using no physician-reported flare as the criterion. TNFi-free survival was significantly different for patient groups based on the number of predictors present, ranging from 21.4% of patients with no predictor present to 66.7% of patients with all three predictors present. Conclusion Patients using an anti-TNF monoclonal antibody, with shorter disease duration and low or moderate baseline MBDA score are most likely to achieve prolonged disease control after TNFi discontinuation. Trial registration Netherlands Trial Register NTR3112, 21 October 2011. Electronic supplementary material The online version of this article (10.1186/s41927-019-0071-x) contains supplementary material, which is available to authorized users.
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Förger F, Bandoli G, Luo Y, Robinson L, Johnson DL, Chambers CD. No Association of Discontinuing Tumor Necrosis Factor Inhibitors Before Gestational Week Twenty in Well-Controlled Rheumatoid Arthritis and Juvenile Idiopathic Arthritis With a Disease Worsening in Late Pregnancy. Arthritis Rheumatol 2019; 71:901-907. [PMID: 30663847 DOI: 10.1002/art.40821] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 12/18/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate whether the discontinuation of tumor necrosis factor inhibitors (TNFi) during pregnancy is associated with any changes of the disease course in women with rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA). METHODS Pregnant women with RA and JIA from the US and Canada were enrolled in the Organization of Teratology Information Specialists (OTIS) Autoimmune Diseases in Pregnancy Project, a prospective cohort study. Information about medication and disease activity (patient-reported outcome measures) was collected prior to gestational week 20 and at gestational week 32. Associations between patterns of TNFi continuation or discontinuation and disease activity changes were tested in unadjusted and multivariate analyses. RESULTS Among 490 women (397 with RA, 93 with JIA) enrolled between 2005 and 2017, 122 (24.9%) discontinued a TNFi before gestational week 20, 201 (41.0%) received a TNFi beyond week 20, and 167 (34.1%) did not receive a TNFi during pregnancy. At the time of enrollment, disease activity was low to minimal in 72.9% of women. TNFi discontinuation was not associated with a clinically important worsening of patient reported outcome measures at the third trimester. Univariate but not multivariate analysis showed that women receiving TNFi beyond week 20 were more likely to experience improved disease activity scores at the third trimester. CONCLUSION Discontinuing TNFi before gestational week 20 seems feasible in women with RA and JIA who enter pregnancy with well-controlled disease.
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Affiliation(s)
- Frauke Förger
- University Hospital and University of Bern, Bern, Switzerland
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15
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Ruscitti P, Sinigaglia L, Cazzato M, Grembiale RD, Triolo G, Lubrano E, Montecucco C, Giacomelli R. Dose adjustments and discontinuation in TNF inhibitors treated patients: when and how. A systematic review of literature. Rheumatology (Oxford) 2018; 57:vii23-vii31. [PMID: 30289540 DOI: 10.1093/rheumatology/key132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives To review the available evidence concerning the possibility of discontinuing and/or tapering the dosage of TNF inhibitors (TNFi) in RA patients experiencing clinical remission or low disease activity. Methods A systematic review of the literature concerning the low dosage and discontinuation of TNFi in disease-controlled RA patients was performed by evaluation of reports published in indexed international journals (Medline via PubMed, EMBASE), in the time frame from 8 April 2013 to 15 January 2016. Results We analysed the literature evaluating the efficacy and the safety of two different strategies using TNFi, decreasing dosage or discontinuation, in patients experiencing clinical remission or low disease activity. After the analysis of online databases, 25 references were considered potentially relevant and 16 references were selected. The majority of data concerned etanercept and adalimumab. Results suggested the induction of stable clinical remission or low disease activity by using TNFi followed by a dosage tapering and/or discontinuation of such drugs may be associated with the maintenance of a good clinical response in a subset of patients affected by early disease. Conclusion RA patients treated early with TNFi and achieving their therapeutic clinical targets seem to maintain their clinical response after tapering or discontinuing TNFi. These data may allow physicians a more dynamic and tailored management of RA patients.
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Affiliation(s)
- Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila
| | | | | | | | - Giovanni Triolo
- Department of Internal Medicine, University of Palermo, Palermo
| | - Ennio Lubrano
- Department of Medicine and Health Science 'Vincenzo Tiberio', University of Molise, Campobasso
| | - Carlomaurizio Montecucco
- Rheumatology and Translational Immunology Research Laboratories (LaRIT) and Biologic Therapy Unit, IRCCS Policlinico San Matteo Foundation/University of Pavia, Pavia, Italy
| | - Roberto Giacomelli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila
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Tran-Duy A, Ghiti Moghadam M, Oude Voshaar MAH, Vonkeman HE, Boonen A, Clarke P, McColl G, Ten Klooster PM, Zijlstra TR, Lems WF, Riyazi N, Griep EN, Hazes JMW, Landewé R, Bernelot Moens HJ, van Riel PLCM, van de Laar MAFJ, Jansen TL. An Economic Evaluation of Stopping Versus Continuing Tumor Necrosis Factor Inhibitor Treatment in Rheumatoid Arthritis Patients With Disease Remission or Low Disease Activity: Results From a Pragmatic Open-Label Trial. Arthritis Rheumatol 2018; 70:1557-1564. [PMID: 29745059 DOI: 10.1002/art.40546] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 04/24/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To evaluate, from a societal perspective, the incremental cost-effectiveness of withdrawing tumor necrosis factor inhibitor (TNFi) treatment compared to continuation of these drugs within a 1-year, randomized trial among rheumatoid arthritis patients with longstanding, stable disease activity or remission. METHODS Data were collected from a pragmatic, open-label trial. Cost-utility analysis was performed using the nonparametric bootstrapping method, and a cost-effectiveness acceptability curve was constructed using the net-monetary benefit framework, where a willingness-to-accept threshold (WTA) was defined as the minimal cost saved that a patient accepted for each quality-adjusted life year (QALY) lost. RESULTS A total of 531 patients were randomized to the stop group and 286 patients to the continuation group. Withdrawal of TNFi treatment resulted in a >60% reduction of the total drug cost, but led to an increase of ∼30% in other health care expenditures. Compared to continuation, stopping TNFi resulted in a mean yearly cost saving of €7,133 (95% confidence interval [95% CI] €6,071, €8,234]) and was associated with a mean loss of QALYs of 0.02 (95% CI 0.002, 0.040). Mean saved cost per QALY lost and per extra flare incurred in the stop group compared to the continuation group was €368,269 (95% CI €155,132, €1,675,909) and €17,670 (95% CI €13,650, €22,721), respectively. At a WTA of €98,438 per QALY lost, the probability that stopping TNFi treatment is cost-effective was 100%. CONCLUSION Although an official WTA is not defined, the mean saved cost of €368,269 per QALY lost seems acceptable in The Netherlands, given existing data on willingness to pay.
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Affiliation(s)
- An Tran-Duy
- Arthritis Center Twente, Medisch Spectrum Twente, and University of Twente, Enschede, The Netherlands
| | - Marjan Ghiti Moghadam
- Arthritis Center Twente, Medisch Spectrum Twente, and University of Twente, Enschede, The Netherlands
| | - Martijn A H Oude Voshaar
- Arthritis Center Twente, Medisch Spectrum Twente, and University of Twente, Enschede, The Netherlands
| | - Harald E Vonkeman
- Arthritis Center Twente, Medisch Spectrum Twente, and University of Twente, Enschede, The Netherlands
| | - Annelies Boonen
- Maastricht University Medical Center and Maastricht University, Maastricht, The Netherlands
| | - Philip Clarke
- University of Melbourne, Melbourne, Victoria, Australia
| | - Geoff McColl
- University of Melbourne, Melbourne, Victoria, Australia
| | - Peter M Ten Klooster
- Arthritis Center Twente, Medisch Spectrum Twente, and University of Twente, Enschede, The Netherlands
| | | | - Willem F Lems
- VU University Medical Center and Reade Medical Center, Amsterdam, The Netherlands
| | - N Riyazi
- Haga Medical Center, The Hague, The Netherlands
| | - E N Griep
- Antonius Medical Center, Sneek, The Netherlands
| | - J M W Hazes
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | | | - Mart A F J van de Laar
- Arthritis Center Twente, Medisch Spectrum Twente, and University of Twente, Enschede, The Netherlands
| | - T L Jansen
- Viecurie Medical Center, Venlo, The Netherlands
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Ghiti Moghadam M, Lamers-Karnebeek FBG, Vonkeman HE, ten Klooster PM, Tekstra J, Schilder AM, Visser H, Sasso EH, Chernoff D, Lems WF, van Schaardenburg DJ, Landewe R, Bernelot Moens HJ, Radstake TRDJ, van Riel PLCM, van de Laar MAFJ, Jansen TL. Multi-biomarker disease activity score as a predictor of disease relapse in patients with rheumatoid arthritis stopping TNF inhibitor treatment. PLoS One 2018; 13:e0192425. [PMID: 29791439 PMCID: PMC5965880 DOI: 10.1371/journal.pone.0192425] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 01/09/2018] [Indexed: 01/04/2023] Open
Abstract
Objective Successfully stopping or reducing treatment for patients with rheumatoid arthritis (RA) in low disease activity (LDA) may improve cost-effectiveness of care. We evaluated the multi-biomarker disease activity (MBDA) score as a predictor of disease relapse after discontinuation of TNF inhibitor (TNFi) treatment. Methods 439 RA patients who were randomized to stop TNFi treatment in the POET study were analyzed post-hoc. Three indicators of disease relapse were assessed over 12 months: 1) restarting TNFi treatment, 2) escalation of any DMARD therapy and 3) physician-reported flare. MBDA score was assessed at baseline. Associations between MBDA score and disease relapse were examined using univariate analysis and multivariate logistic regression. Results At baseline, 50.1%, 35.3% and 14.6% of patients had low (<30), moderate (30−44) or high (>44) MBDA scores. Within 12 months, 49.9% of patients had restarted TNFi medication, 59.0% had escalation of any DMARD and 57.2% had ≥1 physician-reported flare. MBDA score was associated with each indicator of relapse. At least one indicator of relapse was observed in 59.5%, 68.4% and 81.3% of patients with low, moderate or high MBDA scores, respectively (P = 0.004). Adjusted for baseline DAS28-ESR, disease duration, BMI and erosions, high MBDA scores were associated with increased risk for restarting TNFi treatment (OR = 1.85, 95% CI 1.00–3.40), DMARD escalation (OR = 1.99, 95% CI 1.01–3.94) and physician-reported flare (OR = 2.00, 95% 1.06–3.77). Conclusion For RA patients with stable LDA who stopped TNFi, a high baseline MBDA score was independently predictive of disease relapse within 12 months. The MBDA score may be useful for identifying patients at risk of relapse after TNFi discontinuation.
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Affiliation(s)
- Marjan Ghiti Moghadam
- Department of Rheumatology, Medisch Spectrum Twente, Enschede, The Netherlands
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
- * E-mail:
| | | | - Harald E. Vonkeman
- Department of Rheumatology, Medisch Spectrum Twente, Enschede, The Netherlands
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - Peter M. ten Klooster
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - Janneke Tekstra
- Department of Rheumatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Henk Visser
- Department of Rheumatology, Rijnstate, Arnhem, The Netherlands
| | - Eric H. Sasso
- Crescendo Bioscience, Inc., South San Francisco, CA, United States of America
| | - David Chernoff
- Crescendo Bioscience, Inc., South San Francisco, CA, United States of America
| | - Willem F. Lems
- Department of Rheumatology, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Robert Landewe
- Department of Rheumatology, AMC Amsterdam, Amsterdam, the Netherlands
| | | | | | - Piet L. C. M. van Riel
- Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mart A. F. J. van de Laar
- Department of Rheumatology, Medisch Spectrum Twente, Enschede, The Netherlands
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - Tim L. Jansen
- Department of Rheumatology, VieCuri Medical Center, Venlo, The Netherlands
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Chen MH, Lee MH, Liao HT, Chen WS, Lai CC, Tsai CY. Health-related quality of life outcomes in patients with rheumatoid arthritis and ankylosing spondylitis after tapering biologic treatment. Clin Rheumatol 2018; 37:429-438. [DOI: 10.1007/s10067-017-3965-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 12/01/2017] [Accepted: 12/18/2017] [Indexed: 12/19/2022]
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Harrold LR, Stolshek BS, Rebello S, Collier DH, Mutebi A, Wade SW, Malley W, Greenberg JD, Etzel CJ. Rebound in Measures of Disease Activity and Symptoms in Corrona Registry Patients with Psoriatic Arthritis Who Discontinue Tumor Necrosis Factor Inhibitor Therapy after Achieving Low Disease Activity. J Rheumatol 2017; 45:78-82. [PMID: 28966209 DOI: 10.3899/jrheum.161567] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Rebound may occur in patients with psoriatic arthritis (PsA) who discontinue TNF inhibitor (TNFi) therapy in low disease activity (LDA). METHODS Using physician and patient reports, we quantified rebound following TNFi discontinuation [defined as Clinical Disease Activity Index (CDAI) score > 10 or TNFi restart] and time to rebound in adults with PsA in LDA (CDAI score ≤ 10) at TNFi discontinuation. RESULTS Rebound occurred in 73% (69/94) of patients soon after discontinuation (median time to rebound 8.0 mos, 95% CI 6.0-12.0). CONCLUSION Rebound occurred frequently in patients with PsA after TNFi discontinuation. TNFi discontinuation after achieving LDA should be carefully considered.
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Affiliation(s)
- Leslie R Harrold
- From Corrona LLC, Southborough; Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; Amgen Inc., Thousand Oaks, California; Wade Outcomes Research and Consulting, Salt Lake City, Utah; New York University School of Medicine, New York, New York; Department of Epidemiology, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA. .,L.R. Harrold, MD, MPH, Corrona LLC, and Department of Medicine, University of Massachusetts Medical School; B.S. Stolshek, PharmD, Amgen Inc.; S. Rebello, MPH, Corrona LLC; D.H. Collier, MD, Amgen Inc.; A. Mutebi, PhD, Amgen Inc.; S.W. Wade, MPH, Wade Outcomes Research and Consulting; W. Malley, MS, Corrona LLC, and New York University School of Medicine; J.D. Greenberg, MD, MPH, Corrona LLC; C.J. Etzel, PhD, Corrona LLC, and Department of Epidemiology, University of Texas, MD Anderson Cancer Center.
| | - Bradley S Stolshek
- From Corrona LLC, Southborough; Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; Amgen Inc., Thousand Oaks, California; Wade Outcomes Research and Consulting, Salt Lake City, Utah; New York University School of Medicine, New York, New York; Department of Epidemiology, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.,L.R. Harrold, MD, MPH, Corrona LLC, and Department of Medicine, University of Massachusetts Medical School; B.S. Stolshek, PharmD, Amgen Inc.; S. Rebello, MPH, Corrona LLC; D.H. Collier, MD, Amgen Inc.; A. Mutebi, PhD, Amgen Inc.; S.W. Wade, MPH, Wade Outcomes Research and Consulting; W. Malley, MS, Corrona LLC, and New York University School of Medicine; J.D. Greenberg, MD, MPH, Corrona LLC; C.J. Etzel, PhD, Corrona LLC, and Department of Epidemiology, University of Texas, MD Anderson Cancer Center
| | - Sabrina Rebello
- From Corrona LLC, Southborough; Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; Amgen Inc., Thousand Oaks, California; Wade Outcomes Research and Consulting, Salt Lake City, Utah; New York University School of Medicine, New York, New York; Department of Epidemiology, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.,L.R. Harrold, MD, MPH, Corrona LLC, and Department of Medicine, University of Massachusetts Medical School; B.S. Stolshek, PharmD, Amgen Inc.; S. Rebello, MPH, Corrona LLC; D.H. Collier, MD, Amgen Inc.; A. Mutebi, PhD, Amgen Inc.; S.W. Wade, MPH, Wade Outcomes Research and Consulting; W. Malley, MS, Corrona LLC, and New York University School of Medicine; J.D. Greenberg, MD, MPH, Corrona LLC; C.J. Etzel, PhD, Corrona LLC, and Department of Epidemiology, University of Texas, MD Anderson Cancer Center
| | - David H Collier
- From Corrona LLC, Southborough; Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; Amgen Inc., Thousand Oaks, California; Wade Outcomes Research and Consulting, Salt Lake City, Utah; New York University School of Medicine, New York, New York; Department of Epidemiology, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.,L.R. Harrold, MD, MPH, Corrona LLC, and Department of Medicine, University of Massachusetts Medical School; B.S. Stolshek, PharmD, Amgen Inc.; S. Rebello, MPH, Corrona LLC; D.H. Collier, MD, Amgen Inc.; A. Mutebi, PhD, Amgen Inc.; S.W. Wade, MPH, Wade Outcomes Research and Consulting; W. Malley, MS, Corrona LLC, and New York University School of Medicine; J.D. Greenberg, MD, MPH, Corrona LLC; C.J. Etzel, PhD, Corrona LLC, and Department of Epidemiology, University of Texas, MD Anderson Cancer Center
| | - Alex Mutebi
- From Corrona LLC, Southborough; Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; Amgen Inc., Thousand Oaks, California; Wade Outcomes Research and Consulting, Salt Lake City, Utah; New York University School of Medicine, New York, New York; Department of Epidemiology, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.,L.R. Harrold, MD, MPH, Corrona LLC, and Department of Medicine, University of Massachusetts Medical School; B.S. Stolshek, PharmD, Amgen Inc.; S. Rebello, MPH, Corrona LLC; D.H. Collier, MD, Amgen Inc.; A. Mutebi, PhD, Amgen Inc.; S.W. Wade, MPH, Wade Outcomes Research and Consulting; W. Malley, MS, Corrona LLC, and New York University School of Medicine; J.D. Greenberg, MD, MPH, Corrona LLC; C.J. Etzel, PhD, Corrona LLC, and Department of Epidemiology, University of Texas, MD Anderson Cancer Center
| | - Sally W Wade
- From Corrona LLC, Southborough; Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; Amgen Inc., Thousand Oaks, California; Wade Outcomes Research and Consulting, Salt Lake City, Utah; New York University School of Medicine, New York, New York; Department of Epidemiology, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.,L.R. Harrold, MD, MPH, Corrona LLC, and Department of Medicine, University of Massachusetts Medical School; B.S. Stolshek, PharmD, Amgen Inc.; S. Rebello, MPH, Corrona LLC; D.H. Collier, MD, Amgen Inc.; A. Mutebi, PhD, Amgen Inc.; S.W. Wade, MPH, Wade Outcomes Research and Consulting; W. Malley, MS, Corrona LLC, and New York University School of Medicine; J.D. Greenberg, MD, MPH, Corrona LLC; C.J. Etzel, PhD, Corrona LLC, and Department of Epidemiology, University of Texas, MD Anderson Cancer Center
| | - Wendi Malley
- From Corrona LLC, Southborough; Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; Amgen Inc., Thousand Oaks, California; Wade Outcomes Research and Consulting, Salt Lake City, Utah; New York University School of Medicine, New York, New York; Department of Epidemiology, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.,L.R. Harrold, MD, MPH, Corrona LLC, and Department of Medicine, University of Massachusetts Medical School; B.S. Stolshek, PharmD, Amgen Inc.; S. Rebello, MPH, Corrona LLC; D.H. Collier, MD, Amgen Inc.; A. Mutebi, PhD, Amgen Inc.; S.W. Wade, MPH, Wade Outcomes Research and Consulting; W. Malley, MS, Corrona LLC, and New York University School of Medicine; J.D. Greenberg, MD, MPH, Corrona LLC; C.J. Etzel, PhD, Corrona LLC, and Department of Epidemiology, University of Texas, MD Anderson Cancer Center
| | - Jeffrey D Greenberg
- From Corrona LLC, Southborough; Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; Amgen Inc., Thousand Oaks, California; Wade Outcomes Research and Consulting, Salt Lake City, Utah; New York University School of Medicine, New York, New York; Department of Epidemiology, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.,L.R. Harrold, MD, MPH, Corrona LLC, and Department of Medicine, University of Massachusetts Medical School; B.S. Stolshek, PharmD, Amgen Inc.; S. Rebello, MPH, Corrona LLC; D.H. Collier, MD, Amgen Inc.; A. Mutebi, PhD, Amgen Inc.; S.W. Wade, MPH, Wade Outcomes Research and Consulting; W. Malley, MS, Corrona LLC, and New York University School of Medicine; J.D. Greenberg, MD, MPH, Corrona LLC; C.J. Etzel, PhD, Corrona LLC, and Department of Epidemiology, University of Texas, MD Anderson Cancer Center
| | - Carol J Etzel
- From Corrona LLC, Southborough; Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; Amgen Inc., Thousand Oaks, California; Wade Outcomes Research and Consulting, Salt Lake City, Utah; New York University School of Medicine, New York, New York; Department of Epidemiology, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.,L.R. Harrold, MD, MPH, Corrona LLC, and Department of Medicine, University of Massachusetts Medical School; B.S. Stolshek, PharmD, Amgen Inc.; S. Rebello, MPH, Corrona LLC; D.H. Collier, MD, Amgen Inc.; A. Mutebi, PhD, Amgen Inc.; S.W. Wade, MPH, Wade Outcomes Research and Consulting; W. Malley, MS, Corrona LLC, and New York University School of Medicine; J.D. Greenberg, MD, MPH, Corrona LLC; C.J. Etzel, PhD, Corrona LLC, and Department of Epidemiology, University of Texas, MD Anderson Cancer Center
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20
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Lamers-Karnebeek FB, Luime JJ, Ten Cate DF, Teerenstra S, Swen NWAA, Gerards AH, Hendrikx J, van Rooyen EM, Voorneman R, Haagsma C, Basoski N, de Jager M, Ghiti Moghadam M, Efde MN, Goekoop-Ruiterman YPM, van Riel PLCM, Jacobs JWG, Jansen TL. Limited value for ultrasonography in predicting flare in rheumatoid arthritis patients with low disease activity stopping TNF inhibitors. Rheumatology (Oxford) 2017; 56:1560-1565. [PMID: 28595367 DOI: 10.1093/rheumatology/kex184] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Indexed: 11/12/2022] Open
Abstract
Objective Ultrasonography (US) can be used for treatment decisions in RA patients. This study investigated the added value of US to clinical variables in predicting flare in RA patients with longstanding low disease activity when stopping TNF inhibitors (TNFi). Methods Cox models with and without using US added to clinical variables were developed in the Potential Optimization of Expediency of TNFi-UltraSonography study. RA patients (n = 259), using >1 year TNFi and csDMARD with DAS28 < 3.2 for 6 months prior to inclusion, were followed for 52 weeks after stopping TNFi. The added value of US was assessed in two ways: first, by the extent to which individual predictions for flare at 52 weeks with and without US differed; and second, by comparing how US information improved the prediction to classify patients at 52 weeks in the low risk (<33% flare), intermediate risk (33-50%) and high risk (50-100%) groups. Results Although US was predictive of flare at group level (multivariate hazard ratio = 1.7; 95% CI: 1.1, 2.5), individual predictions for flare at 52 weeks with and without US differed little (median difference 3.7%; interquartile range: -7.8 to 6.5%). With US, 15.9% of patients were designated low risk; without US, 14.6%. In fact, 12.0% of patients were US-classified as low risk with/without knowing US. Conclusion In RA patients with longstanding low disease activity, at time of stopping TNFi, US is a predictor for flare at group level, but at the patient level, US has limited added value when common clinical parameters are used already, though the predictive value of clinical predictors is modest as well.
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Affiliation(s)
| | - Jolanda J Luime
- Department of Rheumatology, Erasmus Medical Center, Rotterdam
| | | | - Steven Teerenstra
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Center, Nijmegen
| | | | - Andreas H Gerards
- Department of Rheumatology, Franciscus Gasthuis & Vlietland, Schiedam
| | - Jos Hendrikx
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen
| | - Emma M van Rooyen
- Department of Rheumatology, Radboud University Medical Center, Nijmegen
| | | | - Cees Haagsma
- Department of Rheumatology and Clinical Immunology, Ziekenhuisgroep Twente, Almelo
| | | | - Mike de Jager
- Department of Rheumatology, Albert Schweitzer Hospital, Dordrecht
| | - Marjan Ghiti Moghadam
- Department of Rheumatology, Arthritis Center Twente MST & University of Twente, Enschede
| | - Monique N Efde
- Department of Rheumatology, Viecuri Medicall Center, Venlo
| | | | - Piet L C M van Riel
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen
| | - Johannes W G Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tim L Jansen
- Department of Rheumatology, Viecuri Medicall Center, Venlo
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21
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Ko CH, Chen JF, Cheng TT, Lai HM, Chen YC. Biological tapering and sonographic flare in rheumatoid arthritis. J Investig Med 2017; 66:325-328. [PMID: 28935637 PMCID: PMC5800355 DOI: 10.1136/jim-2017-000558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2017] [Indexed: 11/19/2022]
Abstract
This study aimed to evaluate the risk of ultrasound-detected synovitis after antitumor necrosis factor (TNF) tapering in patients with rheumatoid arthritis. We recruited patients with rheumatoid arthritis who accepted TNF tapering. Gray-scale synovitis and power Doppler score in bilateral wrists at the dorsal radiolunate joint were evaluated. We defined a sum of bilateral wrist scores of ≥2 as sonographic inflammation. Logistical regression analysis was used to adjust for confounding factors. One hundred and twenty-two patients who received a tapered dose of anti-TNF were enrolled, of whom 96 (78%) had ultrasound-detected synovitis and 26 had no inflammation. There were no significant differences in age, gender, body mass index, antinuclear antibodies, rheumatoid factor or anticitrullinated protein antibodies between the inflammation and non-inflammation groups. Moderate tapering of anti-TNF (tapering 50%) was more common in the patients with ultrasound-detected synovitis than mild tapering (tapering 25%) (68.8% vs 38.5%, p=0.005). After adjusting for age, body mass index, gender and a 28-joint Disease Activity Score, the moderate tapering group still had a higher risk of ultrasound-detected synovitis (OR 5.786, 95% CI 1.986 to 16.852; p=0.001); that is, the moderate tapering group had a 5.786 times higher risk of developing sonographic inflammation than the mild tapering group. The dose of biological tapering was the major determinant of ultrasound synovitis. Patients with moderate tapering had a higher risk of synovitis than those with mild tapering. We recommend not tapering by more than 25% to reduce subclinical inflammation and future joint damage.
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Affiliation(s)
- Chi-Hua Ko
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jia-Feng Chen
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tien-Tsai Cheng
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Han-Ming Lai
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Chou Chen
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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22
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Kikuchi J, Kondo T, Shibata A, Sakai R, Okada Y, Chino K, Okuyama A, Kurasawa T, Takei H, Amano K. Efficacy and tolerability of six-week extended dosing interval with tocilizumab therapy in a prospective cohort as remission maintenance in patients with rheumatoid arthritis. Mod Rheumatol 2017; 28:444-451. [PMID: 28849709 DOI: 10.1080/14397595.2017.1366092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To prospectively evaluate the efficacy and tolerability of a six-week extended dosing interval with tocilizumab (TCZ) in patients with rheumatoid arthritis (RA) in sustained remission. METHODS Patients who received over six doses of intravenous TCZ in clinical remission (disease activity score [DAS] 28 - erythrocyte sedimentation rate [ESR] ≤ 2.6) maintained over 3 months between December 2013 and December 2015 were included. Flare was defined as DAS28-ESR >3.2 at two consecutive visits. RESULTS Twenty-five patients were enrolled; 87.5% achieved clinical remission at week 54 after six-week extension and 95.5% achieved a van der Heijde modified total Sharp score (ΔmTSS) ≤0.5. The Health Assessment Questionnaire Disability Index (HAQ-DI) did not increase during 54 weeks. HAQ-DI at baseline and ΔDAS28-ESR at week six positively correlated with increase in DAS28-ESR at week 54. ΔSwollen joint count at week six positively correlated with ΔmTSS at week 54. A total of 12 adverse events occurring in 10 patients did not lead to cessation of TCZ except for one case of recurrent lymphoproliferative disorder at week five. CONCLUSION A six-week extended dosing interval of TCZ for patients with RA in sustained remission is proposed as an acceptable treatment option for maintaining efficacy and tolerability.
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Affiliation(s)
- Jun Kikuchi
- a Department of Rheumatology and Clinical Immunology , Saitama Medical Center, Saitama Medical University , Saitama , Japan.,b Division of Rheumatology, Department of Internal Medicine , Keio University School of Medicine , Tokyo , Japan
| | - Tsuneo Kondo
- a Department of Rheumatology and Clinical Immunology , Saitama Medical Center, Saitama Medical University , Saitama , Japan
| | - Akiko Shibata
- a Department of Rheumatology and Clinical Immunology , Saitama Medical Center, Saitama Medical University , Saitama , Japan
| | - Ryota Sakai
- a Department of Rheumatology and Clinical Immunology , Saitama Medical Center, Saitama Medical University , Saitama , Japan.,c Department of Microbiology and Immunology , Keio University School of Medicine , Tokyo , Japan
| | - Yusuke Okada
- a Department of Rheumatology and Clinical Immunology , Saitama Medical Center, Saitama Medical University , Saitama , Japan
| | - Kentaro Chino
- a Department of Rheumatology and Clinical Immunology , Saitama Medical Center, Saitama Medical University , Saitama , Japan
| | - Ayumi Okuyama
- a Department of Rheumatology and Clinical Immunology , Saitama Medical Center, Saitama Medical University , Saitama , Japan
| | - Takahiko Kurasawa
- a Department of Rheumatology and Clinical Immunology , Saitama Medical Center, Saitama Medical University , Saitama , Japan
| | - Hirofumi Takei
- a Department of Rheumatology and Clinical Immunology , Saitama Medical Center, Saitama Medical University , Saitama , Japan
| | - Koichi Amano
- a Department of Rheumatology and Clinical Immunology , Saitama Medical Center, Saitama Medical University , Saitama , Japan
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23
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Louthrenoo W, Kasitanon N, Katchamart W, Aiewruengsurat D, Chevaisrakul P, Chiowchanwisawakit P, Dechanuwong P, Hanvivadhanakul P, Mahakkanukrauh A, Manavathongchai S, Muangchan C, Narongroeknawin P, Phumethum V, Siripaitoon B, Suesuwan A, Suwannaroj S, Uea-Areewongsa P, Ukritchon S, Asavatanabodee P, Koolvisoot A, Nanagara R, Totemchokchyakarn K, Nuntirooj K, Kitumnuaypong T. 2016 updated Thai Rheumatism Association Recommendations for the use of biologic and targeted synthetic disease-modifying anti-rheumatic drugs in patients with rheumatoid arthritis. Int J Rheum Dis 2017; 20:1166-1184. [DOI: 10.1111/1756-185x.13130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Worawit Louthrenoo
- Division of Rheumatology; Department of Internal Medicine; Faculty of Medicine; Chiang Mai University; Chiang Mai Thailand
| | - Nuntana Kasitanon
- Division of Rheumatology; Department of Internal Medicine; Faculty of Medicine; Chiang Mai University; Chiang Mai Thailand
| | - Wanruchada Katchamart
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Siriraj Hospital, Mahidol University; Bangkok Thailand
| | - Duangkamol Aiewruengsurat
- Division of Rheumatology; Department of Internal Medicine; Faculty of Medicine; Prince of Songkla University; Songkla Thailand
| | - Parawee Chevaisrakul
- Division of Allergy Immunology and Rheumatology; Department of Internal Medicine; Faculty of Medicine; Ramathibodi Hospital, Mahidol University; Bangkok Thailand
| | - Praveena Chiowchanwisawakit
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Siriraj Hospital, Mahidol University; Bangkok Thailand
| | - Pornchai Dechanuwong
- Department of Internal Medicine; Faculty of Medicine; Vajira Hospital, Navamindradhiraj University; Bangkok Thailand
| | - Punchong Hanvivadhanakul
- Division of Rheumatology; Department of Internal Medicine; Faculty of Medicine; Thammasat University; Pathum Thani Thailand
| | - Ajanee Mahakkanukrauh
- Division of Allergy Immunology and Rheumatology; Department of Medicine, Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - Siriporn Manavathongchai
- Department of Internal Medicine; Faculty of Medicine; Vajira Hospital, Navamindradhiraj University; Bangkok Thailand
| | - Chayawee Muangchan
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Siriraj Hospital, Mahidol University; Bangkok Thailand
| | - Pongthorn Narongroeknawin
- Division of Rheumatology, Department of Internal Medicine; Phramongkutklao Hospital and College of Medicine; Bangkok Thailand
| | - Veerapong Phumethum
- Division of Rheumatology, Department of Internal Medicine; Pha Pok Klao Hospital; Chanthaburi Thailand
| | - Boonjing Siripaitoon
- Division of Rheumatology; Department of Internal Medicine; Faculty of Medicine; Prince of Songkla University; Songkla Thailand
| | | | - Siraphop Suwannaroj
- Division of Allergy Immunology and Rheumatology; Department of Medicine, Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - Parichat Uea-Areewongsa
- Division of Rheumatology; Department of Internal Medicine; Faculty of Medicine; Prince of Songkla University; Songkla Thailand
| | - Sittichai Ukritchon
- Division of Rheumatology, Department of Medicine; Faculty of Medicine; Chulalongkorn University; Bangkok Thailand
| | - Paijit Asavatanabodee
- Rheumatic Disease Unit; Department of Medicine; Phramongkutklao Hospital; Bangkok Thailand
| | - Ajchara Koolvisoot
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Siriraj Hospital, Mahidol University; Bangkok Thailand
| | - Ratanavadee Nanagara
- Division of Allergy Immunology and Rheumatology; Department of Medicine, Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - Kitti Totemchokchyakarn
- Division of Allergy Immunology and Rheumatology; Department of Internal Medicine; Faculty of Medicine; Ramathibodi Hospital, Mahidol University; Bangkok Thailand
| | - Kanokrut Nuntirooj
- Division of Allergy Immunology and Rheumatology; Department of Internal Medicine; Faculty of Medicine; Ramathibodi Hospital, Mahidol University; Bangkok Thailand
| | - Tasanee Kitumnuaypong
- Rheumatology Unit; Department of Medicine; Rajavithi Hospital, Ministry of Public Health; Bangkok Thailand
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24
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Ghiti Moghadam M, Vonkeman HE, Ten Klooster PM, Tekstra J, van Schaardenburg D, Starmans-Kool M, Brouwer E, Bos R, Lems WF, Colin EM, Allaart CF, Meek IL, Landewé R, Bernelot Moens HJ, van Riel PLCM, van de Laar MAFJ, Jansen TL. Stopping Tumor Necrosis Factor Inhibitor Treatment in Patients With Established Rheumatoid Arthritis in Remission or With Stable Low Disease Activity: A Pragmatic Multicenter, Open-Label Randomized Controlled Trial. Arthritis Rheumatol 2017; 68:1810-7. [PMID: 26866428 DOI: 10.1002/art.39626] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 02/02/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Tumor necrosis factor inhibitor (TNFi) biologic agents are an effective treatment for rheumatoid arthritis (RA). It is unclear whether patients whose disease is in remission or who have stable low disease activity need to continue use of TNFi or can stop this treatment. This study was undertaken to assess whether patients with established RA who are in remission or have stable low disease activity can effectively and safely stop their TNFi therapy. METHODS The study was designed as a pragmatic multicenter, open-label randomized controlled trial. Inclusion criteria were a diagnosis of RA according to the American College of Rheumatology 1987 classification criteria, as well as use of a TNFi for at least 1 year along with a stable dose of disease-modifying antirheumatic drugs and a Disease Activity Score in 28 joints (DAS28) of <3.2 over the 6 months preceding trial inclusion. Patients were randomized in a 2:1 ratio to either stop or continue treatment with their current TNFi. Flare was defined as a DAS28 of ≥3.2 during the 12-month follow-up period and an increase in score of ≥0.6 compared to the baseline DAS28. RESULTS In total, 531 patients were allocated to the stop group and 286 to the TNFi continuation group. At 12 months, more patients had experienced a flare in the stop group (272 [51.2%] of 531) than in the continuation group (52 [18.2%] of 286; P < 0.001). The hazard ratio for occurrence of a flare after stopping TNFi was 3.50 (95% confidence interval [95% CI] 2.60-4.72). The mean DAS28 in the stop group was significantly higher during the follow-up period compared to that in the continuation group (P < 0.001). Of the 195 patients who restarted TNFi treatment after experiencing a flare and within 26 weeks after stopping, 165 (84.6%) had regained a DAS28 of <3.2 by 6 months later, and the median time to a regained DAS28 of <3.2 was 12 weeks (95% Cl 10.7-13.3). There were more hospitalizations in the stop group than in the continuation group (6.4% versus 2.4%). CONCLUSION Stopping TNFi treatment results in substantially more flares than does continuation of TNFi in patients with established RA in remission or with stable low disease activity.
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Affiliation(s)
- Marjan Ghiti Moghadam
- Arthritis Center Twente Medical Spectrum Twente and University of Twente, Enschede, The Netherlands
| | - Harald E Vonkeman
- Arthritis Center Twente Medical Spectrum Twente and University of Twente, Enschede, The Netherlands
| | - Peter M Ten Klooster
- Arthritis Center Twente Medical Spectrum Twente and University of Twente, Enschede, The Netherlands
| | | | | | - Mirian Starmans-Kool
- Atrium Medical Center, Heerlen, The Netherlands, and Orbis Medical Center, Sittard-Geleen, The Netherlands
| | | | - Reinhard Bos
- Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Willem F Lems
- VU University Medical Center and Reade Medical Center, Amsterdam, The Netherlands
| | - Edgar M Colin
- Hospital Group Almelo, Almelo, The Netherlands, and Hengelo Twente Hospital Group, Hengelo, The Netherlands
| | | | - Inger L Meek
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert Landewé
- Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Hein J Bernelot Moens
- Hospital Group Almelo, Almelo, The Netherlands, and Hengelo Twente Hospital Group, Hengelo, The Netherlands
| | | | - Mart A F J van de Laar
- Arthritis Center Twente Medical Spectrum Twente and University of Twente, Enschede, The Netherlands
| | - Tim L Jansen
- VieCuri Medical Center, Rheumatology, Venlo, The Netherlands
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25
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Ultrasound-detected bone erosion is a relapse risk factor after discontinuation of biologic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis whose ultrasound power Doppler synovitis activity and clinical disease activity are well controlled. Arthritis Res Ther 2017; 19:108. [PMID: 28545509 PMCID: PMC5445491 DOI: 10.1186/s13075-017-1320-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/05/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the present study, we explored the risk factors for relapse after discontinuation of biologic disease-modifying antirheumatic drug (bDMARD) therapy in patients with rheumatoid arthritis (RA) whose ultrasound power Doppler (PD) synovitis activity and clinical disease activity were well controlled. METHODS In this observational study in clinical practice, the inclusion criteria were based on ultrasound disease activity and clinical disease activity, set as low or remission (Disease Activity Score in 28 joints based on erythrocyte sedimentation rate <3.2). Ultrasound was performed in 22 joints of bilateral hands at discontinuation for evaluating synovitis severity and presence of bone erosion. Patients with a maximum PD score ≤1 in each joint were enrolled. Forty patients with RA were consecutively recruited (November 2010-March 2015) and discontinued bDMARD therapy. Variables at the initiation and discontinuation of bDMARD therapy that were predictive of relapse during the 12 months after discontinuation were assessed. RESULTS The median patient age was 54.5 years, and the median disease duration was 3.5 years. Nineteen (47.5%) patients relapsed during the 12 months after the discontinuation of bDMARD therapy. Logistic regression analysis revealed that only the presence of bone erosion detected by ultrasound at discontinuation was predictive of relapse (OR 8.35, 95% CI 1.78-53.2, p = 0.006). No clinical characteristics or serologic biomarkers were significantly different between the relapse and nonrelapse patients. The ultrasound synovitis scores did not differ significantly between the groups. CONCLUSIONS Our findings are the first evidence that ultrasound bone erosion may be a relapse risk factor after the discontinuation of bDMARD therapy in patients with RA whose PD synovitis activity and clinical disease activity are well controlled.
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Doctors' preferences in de-escalating DMARDs in rheumatoid arthritis: a discrete choice experiment. Arthritis Res Ther 2017; 19:78. [PMID: 28446212 PMCID: PMC5405491 DOI: 10.1186/s13075-017-1287-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 03/27/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Current guidelines suggest reduction of DMARDs can be considered in RA patients in remission. Objectives were (1) to estimate the relative importance of patient characteristics rheumatologists consider in their decision to de-escalate (2) to assess whether heterogeneity exists among rheumatologists with respect to de-escalation and (3) to identify the preferred de-escalation strategy. METHODS A discrete choice experiment (DCE) was conducted. All rheumatologists and trainees in The Netherlands were invited to participate. A conditional logit model was estimated to assess overall preference for de-escalation and its determinants. Heterogeneity was estimated by latent class analysis. RESULTS The DCE questionnaire was completed by 156 doctors. This questionnaire was constructed using the results of semi-structured interviews with 12 rheumatologists that identified five patient characteristics relevant for de-escalation: number of swollen joints (SJC), presence of DAS remission/low disease activity (LDA), patient history, duration of remission/LDA and patient willingness to de-escalate DMARDs. Overall SJC and patient history were most important. Latent class analysis revealed five subgroups of doctors, showing differences regarding willingness to de-escalate and relative importance of patient characteristics. De-escalation of the TNF inhibitor rather than methotrexate first was the most preferred strategy. CONCLUSIONS Rheumatologists are not uniform in their decision on whom to de-escalate. Differences emerged in which characteristics they traded off resulting in five subgroups: those that taper (1) always, (2) in absence of swollen joints, (3) in absence of swollen joints and presence of favorable patient history, (4) in DAS remission and favorable patient history, and (5) taking into account all factors.
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van den Brandt S, Zbinden A, Baeten D, Villiger PM, Østensen M, Förger F. Risk factors for flare and treatment of disease flares during pregnancy in rheumatoid arthritis and axial spondyloarthritis patients. Arthritis Res Ther 2017; 19:64. [PMID: 28320445 PMCID: PMC5359860 DOI: 10.1186/s13075-017-1269-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 02/21/2017] [Indexed: 01/25/2023] Open
Abstract
Background During pregnancy, patients with rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) can experience active disease, which might be influenced by adjustment of treatment around conception. The aim of this study was to identify possible risk factors of disease flares during pregnancy and to evaluate the effect of treatment in pregnant patients experiencing a flare. Methods Pregnant patients with RA and axSpA were prospectively followed before, during, and after pregnancy. Disease activity and flares of disease activity were analyzed in regard to medication. Results Among 136 pregnant patients, disease flares during pregnancy occurred in 29% of patients with RA and in 25% of patients with axSpA. In both diseases, active disease and tumor necrosis factor inhibitor (TNFi) discontinuation in early pregnancy were identified as risk factors for disease flares during pregnancy. Of 75 patients with RA, 15 patients were on TNFi and discontinued the treatment at the time of the positive pregnancy test. After stopping TNFi, disease activity increased, which was reflected by peaking C-reactive protein levels at the first trimester. The relative risk of flare in patients with RA stopping TNFi was 3.33 (95% CI 1.8–6.1). Initiation of TNFi or glucocorticosteroid (GC) treatment in 60% of these patients resulted in disease improvement at the second and third trimesters. In comparison, patients with RA without TNFi in the preconception period, most of whom had used pregnancy-compatible antirheumatic drugs, showed mild and stable disease activity before and during pregnancy. Of 61 patients with axSpA, 24 patients were on TNFi and discontinued the treatment at the time of the positive pregnancy test. In patients with axSpA stopping TNFi, a disease aggravation at the second trimester could be observed. The relative risk of flare in this group was 3.08 (95% CI 1.2–7.9). In spite of initiated TNFi or GC treatment in 62.5% of these patients, disease activity remained elevated throughout pregnancy. Patients with axSpA without TNFi in the preconception period showed persistent high disease activity from prepregnancy until the postpartum period. Conclusions On the basis of a risk-benefit analysis, to stabilize disease activity and to prevent a flare during pregnancy in patients with RA and axSpA, tailored medication including TNF inhibitors should be considered beyond conception. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1269-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stephanie van den Brandt
- Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.,Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Astrid Zbinden
- Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Dominique Baeten
- Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Peter M Villiger
- Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Monika Østensen
- Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Frauke Förger
- Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.
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Huynh DH, Boyd TA, Etzel CJ, Cox V, Kremer J, Mease P, Kavanaugh A. Persistence of low disease activity after tumour necrosis factor inhibitor (TNFi) discontinuation in patients with psoriatic arthritis. RMD Open 2017; 3:e000395. [PMID: 28123783 PMCID: PMC5255890 DOI: 10.1136/rmdopen-2016-000395] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 11/30/2016] [Indexed: 11/19/2022] Open
Abstract
Objective To determine the duration of clinical benefit among patients with psoriatic arthritis (PsA) discontinuing tumour necrosis factor inhibitor (TNFi) therapy while in low disease activity (LDA), and to identify patient characteristics associated with prolonged clinical benefit. Methods We performed an observational cohort study assessing patients with PsA from the Consortium of Rheumatology Researchers of North America (CORRONA) registry who had discontinued TNFi after achieving LDA, defined as clinical disease activity index (CDAI) score ≤10 and physician's global assessment (PGA) of skin psoriasis ≤20/100. Kaplan–Meier method was used to estimate the duration of clinical benefit. Results Of the 5945 patients with PsA in CORRONA, 302 patients had discontinued TNFi (n=325) while in LDA and had follow-up data available. At time of discontinuation, mean PsA duration was 9.8 years, mean CDAI was 3.9, and mean duration of TNFi use was 1.5 years; 52.6% of patients had discontinued their first TNFi. Median time to loss of benefit was 29.2 months. 179 (55.1%) patients had persistent benefit at their previous clinic visit. An increased risk of losing clinical benefit was seen among patients with higher disease activity at discontinuation (CDAI≥3.2 vs <3.2; HR 1.43 (p=0.32)) and among smokers (HR 1.78 (p=0.027)). Conclusions Patients with PsA who achieve LDA may maintain clinical benefit after discontinuation of TNFi therapy.
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Affiliation(s)
- D H Huynh
- Allergy and Rheumatology Clinic , La Jolla, California , USA
| | - T A Boyd
- Division of Rheumatology, Department of Medicine , Western University , London, Ontario , Canada
| | - C J Etzel
- Corrona LLC , Southborough, Massachusetts , USA
| | - V Cox
- Corrona LLC , Southborough, Massachusetts , USA
| | - J Kremer
- Corrona LLC , Southborough, Massachusetts , USA
| | - P Mease
- Swedish Medical Center and University of Washington , Seattle, Washington , USA
| | - A Kavanaugh
- Division of Rheumatology, Allergy and Immunology, University of California, San Diego, California, USA; School of Medicine, La Jolla, California, USA
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Schett G, Emery P, Tanaka Y, Burmester G, Pisetsky DS, Naredo E, Fautrel B, van Vollenhoven R. Tapering biologic and conventional DMARD therapy in rheumatoid arthritis: current evidence and future directions. Ann Rheum Dis 2016; 75:1428-37. [DOI: 10.1136/annrheumdis-2016-209201] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 05/16/2016] [Indexed: 01/01/2023]
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Vastesaeger N, Kutzbach AG, Amital H, Pavelka K, Lazaro MA, Moots RJ, Wollenhaupt J, Zerbini CAF, Louw I, Combe B, Beaulieu A, Schulze-Koops H, Dasgupta B, Fu B, Huyck S, Weng HH, Govoni M, Durez P. Prediction of remission and low disease activity in disease-modifying anti-rheumatic drug-refractory patients with rheumatoid arthritis treated with golimumab. Rheumatology (Oxford) 2016; 55:1466-76. [PMID: 27114562 PMCID: PMC4957672 DOI: 10.1093/rheumatology/kew179] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Indexed: 12/22/2022] Open
Abstract
Objective. To create a tool to predict probability of remission and low disease activity (LDA) in patients with RA being considered for anti-TNF treatment in clinical practice. Methods. We analysed data from GO-MORE, an open-label, multinational, prospective study in biologic-naïve patients with active RA (DAS28-ESR ⩾3.2) despite DMARD therapy. Patients received 50 mg s.c. golimumab (GLM) once monthly for 6 months. In secondary analyses, regression models were used to determine the best set of baseline factors to predict remission (DAS28-ESR <2.6) at month 6 and LDA (DAS28-ESR ⩽3.2) at month 1. Results. In 3280 efficacy-evaluable patients, of 12 factors included in initial regression models predicting remission or LDA, six were retained in final multivariable models. Greater likelihood of LDA and remission was associated with being male; younger age; lower HAQ, ESR (or CRP) and tender joint count (or swollen joint count) scores; and absence of comorbidities. In models predicting 1-, 3- and 6-month LDA or remission, area under the receiver operating curve was 0.648–0.809 (R2 = 0.0397–0.1078). The models also predicted 6-month HAQ and EuroQoL-5-dimension scores. A series of matrices were developed to easily show predicted rates of remission and LDA. Conclusion. A matrix tool was developed to show predicted GLM treatment outcomes in patients with RA, based on a combination of six baseline characteristics. The tool could help provide practical guidance in selection of candidates for anti-TNF therapy.
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Affiliation(s)
| | | | - Howard Amital
- Department of Internal Medicine B and Research Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Karel Pavelka
- Institute of Rheumatology and Clinic of Rheumatology, Charles University, Prague, Czech Republic
| | | | - Robert J Moots
- Department of Rheumatology, Clinical Sciences Centre, University Hospital Aintree, Liverpool, UK
| | - Jürgen Wollenhaupt
- Department of Rheumatology, Klinik für Rheumatologie, Schön Klinik Hamburg-Eilbek, Hamburg, Germany
| | - Cristiano A F Zerbini
- Department of Rheumatology, Centro Paulista de Investigação Clinica, São Paulo, Brazil
| | - Ingrid Louw
- Panorama Medical Centre, Cape Town, South Africa
| | - Bernard Combe
- Departement de Rhumatologie, Hôpital Lapeyronie, Montpellier University Hospital, Montpellier, France
| | | | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Department of Medicine IV, University of Munich, Munich, Germany
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital, Westcliff-on-Sea, Essex, UK
| | - Bo Fu
- Department of Biostatistics
| | | | - Haoling H Weng
- Clinical Development, Merck & Co, Inc., Kenilworth, NJ, USA
| | - Marinella Govoni
- Department of Immunology, MSD Italy, Global Medical Affairs, Rome, Italy
| | - Patrick Durez
- Department of Rheumatology, Université Catholique de Louvain, Brussels, Belgium
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Successful Discontinuation of Infliximab in a Refractory Case of Vasculo-Behçet Disease. Case Rep Rheumatol 2016; 2016:1467583. [PMID: 27034879 PMCID: PMC4808526 DOI: 10.1155/2016/1467583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 02/15/2016] [Indexed: 11/17/2022] Open
Abstract
Reports have shown that antitumor necrosis factor alpha (anti-TNF-α) agents including infliximab (IFX) can dramatically suppress the disease activity of refractory vasculo-Behçet disease (vasculo-BD). However, it is completely unknown whether we can discontinue anti-TNF-α agents under clinical remission. A 31-year-old patient with vasculo-BD was initially treated with a high dose of steroid and intravenous cyclophosphamide therapy. Six months later, however, the disease recurred. IFX was administered and immediately the disease activity was reduced. Fortunately, we could discontinue IFX after 18-month remission and no recurrence has been observed. Based on previous reports and our patient, all patients who could discontinue IFX sustained clinical remission for at least one year, continued taking immunosuppressive agents such as methotrexate and azathioprine, and had vascular involvements only in non-life-threatening major vessels such as leg or arm arteries/veins. This is a report suggesting the possibility of discontinuation of IFX in vasculo-BD.
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Boyd T, Kavanaugh A. Novel approaches to biological therapy for psoriatic arthritis. Expert Opin Biol Ther 2015; 16:173-86. [DOI: 10.1517/14712598.2016.1118045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Yoshida K, Radner H, Mjaavatten MD, Greenberg JD, Kavanaugh A, Kishimoto M, Matsui K, Okada M, Reed G, Saeki Y, Tohma S, Kremer J, Solomon DH. Incidence and Predictors of Biological Antirheumatic Drug Discontinuation Attempts among Patients with Rheumatoid Arthritis in Remission: A CORRONA and NinJa Collaborative Cohort Study. J Rheumatol 2015; 42:2238-46. [DOI: 10.3899/jrheum.150240] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2015] [Indexed: 02/03/2023]
Abstract
Objective.We conducted a longitudinal observational study of biological disease-modifying antirheumatic drugs (bDMARD) to describe the proportions of patients with rheumatoid arthritis in remission who discontinued these agents, and to assess the potential predictors of the decision to discontinue.Methods.We used data from the US COnsortium of Rheumatology Researchers Of North America (CORRONA) and the Japanese National Database of Rheumatic Diseases by iR-net in Japan (NinJa) registries, and ran parallel analyses. Patients treated with bDMARD who experienced remission (defined by the Clinical Disease Activity Index ≤ 2.8) were included. The outcome of interest was the occurrence of bDMARD discontinuation while in remission. The predictors of discontinuation were assessed in the Cox regression models. Frailty models were also used to examine the effects of individual physicians in the discontinuation decision.Results.The numbers of eligible patients who were initially in remission were 6263 in the CORRONA and 744 in the NinJa. Among these patients, 10.0% of patients in CORRONA and 11.8% of patients in NinJa discontinued bDMARD while in remission over 5 years, whereas many of the remaining patients lost remission before discontinuing bDMARD. Shorter disease duration was associated with higher rates of discontinuation in both cohorts. In CORRONA, methotrexate use and lower disease activity were also associated with discontinuation. In frailty models, physician random effects were significant in both cohorts.Conclusion.Among patients who initially experienced remission while receiving bDMARD, around 10% remained in remission and then discontinued bDMARD in both registries. Several factors were associated with more frequent discontinuation while in remission. Physician preference likely is also an important correlate of bDMARD discontinuation, indicating the need for standardization of practice.
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Kuijper TM, Lamers-Karnebeek FB, Jacobs JW, Hazes JM, Luime JJ. Flare Rate in Patients with Rheumatoid Arthritis in Low Disease Activity or Remission When Tapering or Stopping Synthetic or Biologic DMARD: A Systematic Review. J Rheumatol 2015; 42:2012-22. [DOI: 10.3899/jrheum.141520] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2015] [Indexed: 11/22/2022]
Abstract
Objective.To evaluate the risk of having a disease flare in patients with rheumatoid arthritis (RA) with low disease activity (LDA) or in remission when deescalating (tapering or stopping) disease-modifying antirheumatic drug (DMARD) therapy.Methods.A search in medical databases including publications from January 1950 to February 2015 was performed. Included were trials and observational studies in adults with RA who were in LDA or remission, evaluating ≥ 20 patients tapering or stopping DMARD. Flare rates had to have been reported. A metaanalysis was performed on studies deescalating tumor necrosis factor (TNF) blockers.Results.Four studies evaluated synthetic DMARD. Flare rates ranged from 8% at 24 weeks to 63% at 4 months after deescalation. Fifteen studies reported on TNF blockers. Estimated flare rates by metaanalysis on studies tapering or stopping TNF blockers were 0.26 (95% CI 0.17–0.39) and 0.49 (95% CI 0.27–0.73) for good-quality and moderate-quality studies, respectively. Flare rates in 3 studies stopping tocilizumab were 41% after 6 months, 55% at 1 year, and 87% at 1 year. Flare rates in 3 studies deescalating abatacept were 34% at 1 year, 41% at 1 year, and 72% at 6 months. Five studies evaluating radiographic progression in patients deescalating treatment all found limited to no progression.Conclusion.Results suggest that more than one-third of patients with RA with LDA or in remission may taper or stop DMARD treatment without experiencing a disease flare within the first year. Dose reduction of TNF blockers results in lower flare rates than stopping and may be noninferior to continuing full dose. Radiological progression after treatment deescalation remains low, but may increase slightly.
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Yoshida K, Kishimoto M, Radner H, Matsui K, Okada M, Saeki Y, Solomon DH, Tohma S. Low rates of biologic-free clinical disease activity index remission maintenance after biologic disease-modifying anti-rheumatic drug discontinuation while in remission in a Japanese multicentre rheumatoid arthritis registry. Rheumatology (Oxford) 2015; 55:286-90. [PMID: 26350484 DOI: 10.1093/rheumatology/kev329] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To examine in detail the outcomes of biologic DMARD (bDMARD) discontinuation while in remission occurring in daily clinical practice settings. We examined a multicentre longitudinal registry of RA patients. METHODS We utilized data from the NinJa multicenter registry in Japan. Patients who used bDMARDs and had one or more successive visits in remission (defined by the clinical disease activity index (CDAI) ≤2.8) before discontinuation were included. The outcome of failing bDMARD-free disease control was defined as a composite of the following: re-use of bDMARDs, intensification of non-biologic DMARDs or of oral glucocorticoids, or loss of CDAI remission. RESULTS Among 1037 patients who initially achieved remission on bDMARDs, 46 patients discontinued bDMARDs while remaining in remission. Of these 46 subjects, 41 (89.1%) were female, the median disease duration was 6.0 years and 31 (70.5%) had reported radiographical erosions. At the baseline, 27 (58.7%) used MTX and 19 (41.3%) used oral glucocorticoids. The bDMARD-free remission failure rate was estimated to be 67.4% at 1 year and 78.3% at 2 years. Loss of remission and reuse of bDMARDs were the more common reasons for failure. Lower CDAI within the remission range was associated with fewer failures. CONCLUSION We found a high rate of failing bDMARD-free CDAI remission, indicating difficulty of maintaining disease control, even in patients who were in remission. Modification of non-biologic treatment was observed in some of the patients who remained in remission. Considering the cost of bDMARDs, such strategies for maintaining disease control after bDMARD discontinuation may be an important option.
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Affiliation(s)
- Kazuki Yoshida
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA,
| | - Mitsumasa Kishimoto
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Helga Radner
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA, Department of Internal Medicine III, Division of Rheumatology, Medical University Vienna, Vienna, Austria
| | - Kazuo Matsui
- Department of Rheumatology, Kameda Medical Center, Kamogawa
| | - Masato Okada
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Yukihiko Saeki
- Department of Clinical Research, National Hospital Organization Osaka Minami Medical Center, Kawachinagano, Osaka and
| | - Daniel H Solomon
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
| | - Shigeto Tohma
- Department of Rheumatology, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Japan
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