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Chaudhary H, Bittar M, Daoud A, Magrey M. Dose Tapering and Discontinuation of Biologic DMARDs in Axial Spondyloarthritis: A Narrative Review (2023 SPARTAN Annual Meeting Proceedings). Curr Rheumatol Rep 2024; 26:155-163. [PMID: 38332457 PMCID: PMC11062993 DOI: 10.1007/s11926-024-01137-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE OF REVIEW Limited data is available for tapering or discontinuation of biologic therapy in patients with axSpA who are in disease remission. The current review concentrates on published studies regarding dose tapering or withdrawal of biologics in axSpA. RECENT FINDINGS Recent evidence in light of randomized controlled trials suggests that tapering of b-DMARDs is a feasible strategy to maintain remission or low disease activity in axSpA patients. TNF inhibitors were the studied biologics in most of these trials. The disease flare rates were comparable to those maintained on standard dose in most of these studies, although with variable tapering strategies and follow-up. Additionally, the duration of disease in remission prior to tapering, studied primary outcome, and flare definitions were heterogeneous. Female sex, HLA-B*27 negativity, high physician global score, and high CRP were negative predictors of successful tapering, but not consistently reported in all the trials. Although designed to address efficacy, there were no safety concerns with b-DMARD tapering. Withdrawal or complete discontinuation of biologics met with increased risk of flares compared to standard dosing. Tapering of TNF inhibitors may be feasible in certain axSpA patients with an acceptable disease state; however, discontinuation is not currently recommended owing to increased risk of flare. Future studies with axSpA patients with longer remission duration prior to taper and different doses and types of b-DMARDs may provide more guidance.
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Affiliation(s)
- Haseeb Chaudhary
- Department of Rheumatology, Case Western Reserve University, University Hospitals, Cleveland, OH, USA.
| | - Mohamad Bittar
- Division of Arthritis and Rheumatic Diseases, Oregon Health and Science University, Portland, OR, USA
| | - Ansaam Daoud
- Department of Rheumatology, Case Western Reserve University, University Hospitals, Cleveland, OH, USA
| | - Marina Magrey
- Department of Rheumatology, Case Western Reserve University, University Hospitals, Cleveland, OH, USA
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Seo MR, Yeo J, Park JW, Lee YA, Lee JH, Kang EH, Ji SM, Kwon SR, Kim SK, Kim TJ, Kim TH, Kim HW, Park MC, Shin K, Lee SH, Lee EY, Cha HS, Shim SC, Yoon Y, Lee SH, Lim JH, Baek HJ. Korean treatment recommendations for patients with axial spondyloarthritis. Korean J Intern Med 2023; 38:620-640. [PMID: 37482652 PMCID: PMC10493447 DOI: 10.3904/kjim.2023.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 07/25/2023] Open
Abstract
We aimed to develop evidence-based recommendations for treating axial spondylarthritis (axSpA) in Korea. The development committee was constructed, key clinical questions were determined, and the evidence was searched through online databases including MEDLINE, Embase, Cochrane, KoreaMed, and Kmbase. Systematic literature reviews were conducted, quality of evidence was determined, and draft recommendations were formulated according to the Grading of Recommendations Assessment, Development, and Evaluations methodology. Recommendations that reached 80% consensus among a voting panel were finalized. Three principles and 21 recommendations were determined. Recommendations 1 and 2 pertain to treatment strategies, regular disease status assessment, and rheumatologist-steered multidisciplinary management. Recommendations 3 and 4 strongly recommend patient education, exercise, and smoking cessation. Recommendations 5-12 address pharmacological treatment of active disease using nonsteroidal anti-inflammatory drugs, glucocorticoids, sulfasalazine, biologics, and Janus kinase inhibitors. Recommendations 13-16 address treatment in stable disease. We suggest against spa and acupuncture as therapies (Recommendation 17). Recommendations 18 and 19 pertain to total hip arthroplasty and spinal surgery. Monitoring of comorbidities and drug toxicities are recommended (Recommendations 20 and 21). Recommendations for axSpA treatment in a Korean context were developed based on comprehensive clinical questions and evidence. These are intended to guide best practice in the treatment of axSpA.
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Affiliation(s)
- Mi Ryoung Seo
- Division of Rheumatology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon,
Korea
| | - Jina Yeo
- Division of Rheumatology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon,
Korea
| | - Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
| | - Yeon-Ah Lee
- Division of Rheumatology, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul,
Korea
| | - Ju Ho Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Eun Ha Kang
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Seon Mi Ji
- National Health Insurance Service, Wonju,
Korea
| | - Seong-Ryul Kwon
- Division of Rheumatology, Department of Internal Medicine, Inha University College of Medicine. Incheon,
Korea
| | - Seong-Kyu Kim
- Division of Rheumatology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu,
Korea
| | - Tae-Jong Kim
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School and Hospital, Gwangju,
Korea
| | - Tae-Hwan Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul,
Korea
| | - Hye Won Kim
- Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Min-Chan Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul,
Korea
| | - Kichul Shin
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul,
Korea
| | - Sang-Hoon Lee
- Department of Rheumatology, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul,
Korea
| | - Eun Young Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
| | - Hoon Suk Cha
- Division of Rheumatology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Seung Cheol Shim
- Division of Rheumatology, Daejeon Rheumatoid & Degenerative Arthritis Center, Chungnam National University Hospital. Daejeon,
Korea
| | - Youngim Yoon
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
| | - Seung Ho Lee
- Korea Ankylosing Spondylitis Society, Seoul,
Korea
| | - Jun Hong Lim
- Korea Ankylosing Spondylitis Corporation, Daejeon,
Korea
| | - Han Joo Baek
- Division of Rheumatology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon,
Korea
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Seo MR, Yeo J, Park JW, Lee YA, Lee JH, Kang EH, Ji SM, Kwon SR, Kim SK, Kim TJ, Kim TH, Kim HW, Park MC, Shin K, Lee SH, Lee EY, Cha HS, Shim SC, Yoon Y, Lee SH, Lim JH, Baek HJ. Korean treatment recommendations for patients with axial spondyloarthritis. JOURNAL OF RHEUMATIC DISEASES 2023; 30:151-169. [PMID: 37476674 PMCID: PMC10351367 DOI: 10.4078/jrd.2023.0025] [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] [Received: 05/03/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 07/22/2023]
Abstract
We aimed to develop evidence-based recommendations for treating axial spondylarthritis (axSpA) in Korea. The development committee was constructed, key clinical questions were determined, and the evidence was searched through online databases including MEDLINE, Embase, Cochrane, KoreaMed, and KMbase. Systematic literature reviews were conducted, quality of evidence was determined, and draft recommendations were formulated according to the Grading of Recommendations Assessment, Development, and Evaluations methodology. Recommendations that reached 80% consensus among a voting panel were finalized. Three principles and 21 recommendations were determined. Recommendations 1 and 2 pertain to treatment strategies, regular disease status assessment, and rheumatologist-steered multidisciplinary management. Recommendations 3 and 4 strongly recommend patient education, exercise, and smoking cessation. Recommendations 5~12 address pharmacological treatment of active disease using nonsteroidal anti-inflammatory drugs, glucocorticoids, sulfasalazine, biologics, and Janus kinase inhibitors. Recommendations 13~16 address treatment in stable disease. We suggest against spa and acupuncture as therapies (Recommendation 17). Recommendations 18 and 19 pertain to total hip arthroplasty and spinal surgery. Monitoring of comorbidities and drug toxicities are recommended (Recommendations 20 and 21). Recommendations for axSpA treatment in a Korean context were developed based on comprehensive clinical questions and evidence. These are intended to guide best practice in the treatment of axSpA.
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Affiliation(s)
- Mi Ryoung Seo
- Division of Rheumatology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jina Yeo
- Division of Rheumatology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yeon-Ah Lee
- Division of Rheumatology, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Ju Ho Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Ha Kang
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seon Mi Ji
- National Health Insurance Service, Wonju, Korea
| | - Seong-Ryul Kwon
- Division of Rheumatology, Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Seong-Kyu Kim
- Division of Rheumatology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Tae-Jong Kim
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Tae-Hwan Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Hye Won Kim
- Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Min-Chan Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kichul Shin
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Sang-Hoon Lee
- Department of Rheumatology, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Eun Young Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hoon Suk Cha
- Division of Rheumatology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Cheol Shim
- Division of Rheumatology, Daejeon Rheumatoid & Degenerative Arthritis Center, Chungnam National University Hospital, Daejeon, Korea
| | - Youngim Yoon
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Ho Lee
- Korea Ankylosing Spondylitis Society, Seoul, Korea
| | - Jun Hong Lim
- Korea Ankylosing Spondylitis Corporation, Daejeon, Korea
| | - Han Joo Baek
- Division of Rheumatology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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Luo G, Zhu J. Etanercept in axial spondyloarthritis. Chin Med J (Engl) 2022; 135:2628-2630. [PMID: 35261349 PMCID: PMC9945552 DOI: 10.1097/cm9.0000000000001986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Indexed: 01/26/2023] Open
Affiliation(s)
- Gui Luo
- Department of Rheumatology and Immunology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
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De-escalation of Anti-tumor Necrosis Factor Alpha Agents and Reduction in Adverse Effects: A Systematic Review. Biomedicines 2022; 10:biomedicines10051034. [PMID: 35625771 PMCID: PMC9139158 DOI: 10.3390/biomedicines10051034] [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: 03/26/2022] [Revised: 04/20/2022] [Accepted: 04/27/2022] [Indexed: 12/04/2022] Open
Abstract
Background: The long-term use of anti-TNF-α agents can lead to adverse effects, such as infections and immune-mediated cutaneous reactions. Whether de-escalation by dose reduction or interval lengthening reduces these adverse effects is uncertain. This systematic review aims to compare the incidence of infections and skin manifestations after anti-TNF-α dose de-escalation with standard dosing. Methods: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from inception to 14 January 2022. Randomized controlled trials (RCTs) and observational studies comparing anti-TNF-α de-escalation strategies with standard dosing among patients with inflammatory conditions, that report on infections, skin manifestations, or both, were included. The risk of bias was assessed with the revised Cochrane risk-of bias tool (RCTs) or the Newcastle–Ottawa scale (non-RCTs). Results: Fourteen RCTs and six observational studies (or 2706 patients) were included. Eight RCTs had low risk of bias or some concerns. Four non-RCTs were of good methodological quality. The studies described patients with axial spondyloarthritis (8 studies, 780 patients), rheumatoid arthritis (7 studies, 1458 patients), psoriasis (3 studies, 332 patients), or inflammatory bowel disease (2 studies, 136 patients). De-escalation strategies included interval lengthening (12 studies, 1317 patients), dose reduction (6 studies, 1130 patients), or both (2 studies, 259 patients). Overall, the occurrence of infections and skin manifestations did not differ between standard treatment and de-escalation. The disappearance of infections or skin manifestations after de-escalation was only reported in two studies. The majority of studies focused on etanercept and adalimumab. Heterogeneity in reporting of infections and skin manifestations precluded meta-analysis. Conclusion: We found that anti-TNF-α de-escalation does not reduce infections or skin reactions. A de-escalation strategy should not be recommended for the sole purpose of reducing drug-related adverse effects. The meticulous documentation of adverse effects is recommended to further address this question. Registration: PROSPERO CRD42021252977.
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Koo BS, Lim YC, Lee MY, Jeon JY, Yoo HJ, Oh IS, Shin JY, Kim TH. Dose Reduction of Tumor Necrosis Factor Inhibitor and its Effect on Medical Costs for Patients with Ankylosing Spondylitis. Rheumatol Ther 2021; 8:347-359. [PMID: 33420967 PMCID: PMC7991020 DOI: 10.1007/s40744-020-00274-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/19/2020] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Tumor necrosis factor inhibitors (TNFis) may be administered at a reduced dose to patients with ankylosing spondylitis (AS) for various reasons. However, in practice, there is insufficient evidence of how the dose reduction of TNFi is implemented and the amount of medical costs it reduces. In this study, we investigated treatment patterns among patients with AS who were administered various TNFis. The effect on medical costs related to AS was also investigated using Korea's insurance claims database. METHODS From the insurance claims database of the Health Insurance Review & Assessment Service in South Korea, patients with AS newly treated with TNFis (etanercept, adalimumab, golimumab, and infliximab) between July 1, 2013, and June 30, 2016, were enrolled. Patients treated with the TNFis were followed up for 2 years. Treatment patterns (continuation and discontinuation of TNFi) and dose reduction (< 50% of recommended dose) in patients who continued treatment were analyzed and compared among the TNFi groups using the Chi-square test. Healthcare costs between the dose reduction and maintenance groups were compared using general linear modeling. RESULTS Of 1352 patients, 764 (56.51%) continued using TNFis for 2 years, and 17.8% of these were administered reduced doses. TNFi dose reduction was the most frequent in 36 (24.83%) patients using etanercept, followed by those using adalimumab (21.97%), golimumab (11.70%), and infliximab (11.98%) (p = 0.0028). For each TNFi group, the total healthcare cost significantly decreased, that is, by 24.85% for adalimumab, 31.80% for etanercept, 26.34% for golimumab, and 35.52% for infliximab (p < 0.0001). CONCLUSIONS TNFi dose reduction was identified in 17.8% of the patients with AS, and the patterns were different for each TNFi. Additionally, the dose reductions significantly reduced the medical costs associated with AS, that is, from 24.85 to 35.52% of the total medical expenditure.
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Affiliation(s)
- Bon San Koo
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Yu-Cheol Lim
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, Republic of Korea
| | | | | | | | - In-Sun Oh
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, Republic of Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, Republic of Korea
| | - Tae-Hwan Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea.
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ÖZER HTE. Remisyonda olan ankilozan spondilit hastasında tedavi kararı. EGE TIP DERGISI 2021. [DOI: 10.19161/etd.863658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Zhang T, Zhu J, He D, Chen X, Wang H, Zhang Y, Xue Q, Liu W, Xiang G, Li Y, Yu Z, Wu H. Disease activity guided stepwise tapering or discontinuation of rhTNFR:Fc, an etanercept biosimilar, in patients with ankylosing spondylitis: a prospective, randomized, open-label, multicentric study. Ther Adv Musculoskelet Dis 2020; 12:1759720X20929441. [PMID: 32536984 PMCID: PMC7268122 DOI: 10.1177/1759720x20929441] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/05/2020] [Indexed: 12/17/2022] Open
Abstract
Background The aim of this study was to evaluate disease-activity-guided stepwise tapering or discontinuation of rhTNFR:Fc, an etanercept biosimilar, in patients with ankylosing spondylitis (AS) in a prospective, randomized, open-label, multicentric study. Methods Active AS patients with AS disease activity score (ASDAS) ⩾2.1 recruited from 10 hospitals were treated with rhTNFR:Fc 50 mg weekly for 12 weeks, and further randomized into different tapering or discontinuation groups according to ASDAS at week 12. Patients who achieved clinical remission (ASDAS < 1.3) were assigned randomly to stepwise tapering group or discontinuation group. Patients who achieved low disease activity (LDA, 1.3⩽ASDAS < 2.1) were assigned randomly to stepwise tapering, delayed tapering, or discontinuation group. All patients were evaluated every 12 weeks until week 48. The primary endpoint was cumulative flare rates in different groups at week 48. Results A total of 311 patients were enrolled with an average ASDAS of 3.6 ± 1.0, and 259 completed 12 weeks of rhTNFR:Fc induction therapy, with 148 patients (57.1%) achieved clinical remission, 100 (38.6%) achieved LDA, and 11 (4.3%) remained as high disease activity (ASDAS⩾2.1). In patients who achieved clinical remission at week 12, stepwise tapering of rhTNFR:Fc demonstrated significantly lower flare rates at each evaluation compared with discontinuation. In patients who achieved LDA, there was no significant difference of flare rates between stepwise tapering, delayed tapering, and discontinuation. With stepwise tapering of rhTNFR:Fc, flare rates were comparable in AS patients, irrespective of initial ASDAS before tapering. Conclusion Stepwise tapering of rhTNFR:Fc when patients achieved clinical remission was able to maintain favorable low flare rates in 48 weeks. LDA was an alternative therapeutic target, as well as an viable timing for initiation of rhTNFR:Fc tapering. rhTNFR:Fc 25 mg monthly maintained flare-free status in a considerable number of patients. However, abrupt discontinuation of rhTNFR:Fc even if patients achieved clinical remission should be avoided. Trial registration ClinicalTrials.gov: NCT03880968,URL: https://clinicaltrials.gov/ct2/show/NCT03880968.
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Affiliation(s)
- Ting Zhang
- Division of Rheumatology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jianing Zhu
- Division of Rheumatology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Dongyi He
- Division of Rheumatology, Shanghai Guanghua Integrative Medicine Hospital Affiliated to Shanghai University of Tradition Chinese Medicine, Shanghai, China
| | - Xiaowei Chen
- Division of Rheumatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hongzhi Wang
- Division of Rheumatology, the First Hospital of Jiaxing, Jiaxing, China
| | - Ying Zhang
- Division of Rheumatology, Shaoxing Second Hospital, Shaoxing, Zhejiang, China
| | - Qin Xue
- Division of Rheumatology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Weili Liu
- Division of Rheumatology, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Guangbo Xiang
- Division of Rheumatology, Wenzhou Central Hospital, Wenzhou, China
| | - Yasong Li
- Division of Rheumatology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Zhongming Yu
- Division of Rheumatology, Shaoxing People's Hospital, Shaoxing, China
| | - Huaxiang Wu
- Division of Rheumatology, the Second Affiliated Hospital of Zhejiang University School of Medicine, No.88, Jiefang Road, Hangzhou 310009, China
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Van Rossen L, Chan A, Gilbert A, Gaffney K, Harris C, Machado PM, Santos LR, Sengupta R, Basset P, Keat A. Response to lower dose TNF inhibitors in axial spondyloarthritis; a real-world multicentre observational study. Rheumatol Adv Pract 2020; 4:rkaa015. [PMID: 32793854 PMCID: PMC7415263 DOI: 10.1093/rap/rkaa015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Dose optimization of TNF inhibitors in axial spondyloarthritis (axSpA) is attractive, but it is unclear for which patients this approach might be appropriate. METHODS Seventy-one patients with axSpA, from six UK centres, were identified who had reduced their dose of TNF inhibitor after being considered to be stable responders. All completed a questionnaire concerning their approach to and experience of dose reduction. Data on patient characteristics, metrology and CRP were retrieved retrospectively from patient records. RESULTS Over 2 years of observation, 60 (84.5%) remained (REM) on reduced-dose medication and 11 (15.5%) reverted (REV) to the original dose. The overall mean dose reduction was 39% for REM patients and 44% for REV patients. Both groups initially responded in a similar manner to treatment, but the data showed a trend that younger women were more likely to revert. Neither BMI nor smoking was associated with continued low-dose responsiveness. Eight of the 11 REV patients reverted by 6 months. None reached criteria of secondary drug failure, and all regained control after increasing back to the original dose. Most patients in both groups reached the decision to reduce the dose jointly with clinicians. A preference for taking the reduced dose was not associated with low-dose drug survival. CONCLUSION Many patients with axSpA remain well symptomatically after stepping down the dose of TNF inhibitor, but young women are less likely to do well on a reduced dose. Dose reduction should be one element of the management of patients with axSpA.
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Affiliation(s)
- Liz Van Rossen
- Department of Research and Development, East Kent Hospital University Foundation Trust, Canterbury
| | - Antoni Chan
- Department of Rheumatology, Royal Berkshire Hospital, Reading
| | | | - Karl Gaffney
- Department of Rheumatology, Norfolk and Norwich University Foundation Trust, Norwich
| | - Claire Harris
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London
| | - Pedro M Machado
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London
- Department of Rheumatology & Queen Square Centre for Neuromuscular Diseases, University College London Hospitals NHS Foundation Trust, London
| | - Liliana R Santos
- Department of Rheumatology & Queen Square Centre for Neuromuscular Diseases, University College London Hospitals NHS Foundation Trust, London
| | - Raj Sengupta
- Department of Rheumatology, Royal United Hospitals Trust, Bath
| | | | - Andrew Keat
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London
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Vinson D, Molet-Benhamou L, Degboé Y, den Broeder A, Ibrahim F, Pontes C, Westhovens R, Závada J, Pham T, Barnetche T, Constantin A, Ruyssen-Witrand A. Impact of tapering targeted therapies (bDMARDs or JAKis) on the risk of serious infections and adverse events of special interest in patients with rheumatoid arthritis or spondyloarthritis: a systematic analysis of the literature and meta-analysis. Arthritis Res Ther 2020; 22:97. [PMID: 32349791 PMCID: PMC7191828 DOI: 10.1186/s13075-020-02188-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 04/17/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To systematically review the impact of tapering targeted therapies (bDMARDs or JAKis) on the risk of serious infections and severe adverse events (SAEs) in patients with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) in remission or low disease activity (LDA) state. MATERIALS AND METHODS A meta-analysis based on a systematic review of PubMed, Embase, Cochrane, until August 2019, as well as relevant databases of international conferences, was used to evaluate the risk difference (RD) at 95% confidence interval (95% CI) of incidence density of serious infections, SAEs, malignancies, cardiovascular adverse events (CV AEs), or deaths after tapering (dose reduction or spacing) compared to continuation of targeted therapies. RESULTS Of the 1957 studies initially identified, 13 controlled trials (9 RA and 4 SpA trials) were included in the meta-analysis. 1174 patient-years were studied in the tapering group (TG) versus 1086 in the usual care group (UC). There were 1.7/100 patient-year (p-y) serious infections in TG versus 2.6/100 p-y in UC (RD (95% CI) 0.01 (0.00 to 0.02), p = 0.13) and 7.4/100 p-y SAEs in TG versus 6.7/100 p-y in UC (RD 0.00 (- 0.02 to 0.02), p = 0.82). The risk of malignancies, CV AEs, or deaths did not differ between the tapering and the usual care groups. Subgroup analysis (RA and SpA) detected no significant differences between the two groups. CONCLUSION We could not show significant impact of tapering bDMARD or JAKi over continuation concerning the risk of serious infections, SAEs, malignancies, CV AEs, or deaths in RA and SpA patients in remission or LDA state.
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Affiliation(s)
- D Vinson
- Rheumatology Department, CHU Sainte Marguerite, 270 Boulevard de Sainte-Marguerite, 13009, Marseille, France.
| | | | - Y Degboé
- INSERM U1043, CPTP, Toulouse, France
| | - A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, 6500 GM, Nijmegen, The Netherlands
| | - F Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences, King's College London, Cutcombe Road, London, SE5 9RJ, UK
| | - C Pontes
- Department of Pharmacology, Therapeutics and Toxicology, Unitat docent Parc Taulí-Medical School-Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - R Westhovens
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, Rheumatology University Hospitals Leuven, KULeuven, Leuven, Belgium
| | - J Závada
- First Faculty of Medicine, Institute of Rheumatology and Department of Rheumatology, Charles University, Na Slupi 4, Prague, Czech Republic
| | - T Pham
- Rheumatology Department, CHU Sainte Marguerite, 270 Boulevard de Sainte-Marguerite, 13009, Marseille, France
| | - T Barnetche
- Rheumatology Department, Pellegrin Hospital, Bordeaux, France
| | - A Constantin
- Rheumatology Department, Hôpital Purpan, Toulouse, France
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11
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Michielsens CAJ, Boers N, den Broeder N, Wenink MH, van der Maas A, Mahler EAM, Mulder MLM, van der Heijde D, van den Hoogen FHJ, Verhoef LM, den Broeder AA. Dose reduction and withdrawal strategy for TNF-inhibitors in psoriatic arthritis and axial spondyloarthritis: design of a pragmatic open-label, randomised, non-inferiority trial. Trials 2020; 21:90. [PMID: 31941544 PMCID: PMC6964104 DOI: 10.1186/s13063-019-4000-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/16/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Tumour necrosis factor inhibitors (TNFi) are effective in the treatment of patients with spondyloarthritis (SpA), including psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA). However, these drugs come with some disadvantages such as adverse events, practical burden for patients and high costs. Dose optimisation of TNFi after patients have reached low disease activity (LDA) has been shown feasible and safe in rheumatoid arthritis (RA). However, data on TNFi dose optimisation in PsA and axSpA are scarce, especially pragmatic, randomised strategy studies. METHODS We developed an investigator-driven, pragmatic, open-label, randomised, controlled, non-inferiority trial (DRESS-PS) to compare the effects of a disease activity-guided treat-to-target strategy with or without a tapering attempt in patients with SpA (PsA and axSpA combined), ≥ 16 years of age, who are being treated with TNFi, and have had at least 6 months of low disease activity. The primary outcome is the percentage of patients in LDA after 12 months of follow up. Patients are assessed at baseline, 3, 6, 9, and 12 months of follow up. Bayesian power analyses with a weakened prior based on a similar study performed in RA resulted in a sample size of 95 patients in total. DISCUSSION More knowledge on disease activity-guided treatment algorithms would contribute to better treatment choices and cost savings and potentially decrease the risk of side effects. In this article we elucidate some of our design choices on TNFi dose optimisation and its clinical and methodological consequences. TRIAL REGISTRATION Dutch Trial Register, NL6771. Registered on 27 November 2018 (CMO NL66181.091.18, 23 October 2018).
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Affiliation(s)
- Celia A J Michielsens
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands. .,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Nadine Boers
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Mark H Wenink
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Elien A M Mahler
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Michelle L M Mulder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands.,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands.,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands.,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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12
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Wei JCC, Liu CH, Tseng JC, Hsieh LF, Chen CH, Chen HH, Chen HA, Chen YC, Chou CT, Liao HT, Lin YC, Luo SF, Yang DH, Yeo KJ, Tsai WC. Taiwan Rheumatology Association consensus recommendations for the management of axial spondyloarthritis. Int J Rheum Dis 2019; 23:7-23. [PMID: 31777200 PMCID: PMC7004149 DOI: 10.1111/1756-185x.13752] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 03/31/2019] [Indexed: 12/16/2022]
Abstract
Aim To establish guidelines for the clinical management of axial spondyloarthritis that take into account local issues and clinical practice concerns for Taiwan. Method Overarching principles and recommendations were established by consensus among a panel of rheumatology and rehabilitation experts, based on analysis of the most up‐to‐date clinical evidence and the clinical experience of panelists. All Overarching Principles and Recommendations were graded according to the standards developed by the Oxford Centre for Evidence Based Medicine, and further evaluated and modified using the Delphi method. Results The guidelines specifically address issues such as local medical considerations, National Health Insurance reimbursement, and management of extra‐articular manifestations. Conclusion It is hoped that this will help to optimize clinical management outcomes for axial spondyloarthritis in Taiwan.
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Affiliation(s)
- James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| | - Chin-Hsiu Liu
- Division of Allergy, Immunology and Rheumatology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jui-Cheng Tseng
- Division of Allergy, Immunology, and Rheumatology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Lin-Fen Hsieh
- Department of Physical Medicine and Rehabilitation, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.,School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chun-Hsiung Chen
- Division of Allergy, Immunology and Rheumatology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Hsin-Hua Chen
- Division of Allergy-Immunology-Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hung-An Chen
- Department of Allergy, Immunology, and Rheumatology, Chi Mei Medical Center, Tainan, Taiwan
| | - Ying-Chou Chen
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital-Kaohsiung, Kaohsiung, Taiwan
| | - Chung-Tei Chou
- Division of Allergy, Immunology, Rheumatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsien-Tzung Liao
- Division of Allergy, Immunology, Rheumatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Chun Lin
- Department of Allergy, Immunology, and Rheumatology, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Shue-Fen Luo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan
| | - Deng-Ho Yang
- Division of Rheumatology/Immunology/Allergy, Department of Internal Medicine, Taichung Armed-Forces General Hospital, Taichung, Taiwan.,Department of Medical Laboratory Science and Biotechnology, Central Taiwan University of Science and Technology, Taichung, Taiwan.,Division of Rheumatology/Immunology/Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Kai-Jieh Yeo
- Division of Rheumatology and Immunology, China Medical University Hospital, Taichung, Taiwan
| | - Wen-Chan Tsai
- Division of Allergy, Immunology, and Rheumatology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
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13
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Ward MM, Deodhar A, Gensler LS, Dubreuil M, Yu D, Khan MA, Haroon N, Borenstein D, Wang R, Biehl A, Fang MA, Louie G, Majithia V, Ng B, Bigham R, Pianin M, Shah AA, Sullivan N, Turgunbaev M, Oristaglio J, Turner A, Maksymowych WP, Caplan L. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol 2019; 71:1599-1613. [PMID: 31436036 DOI: 10.1002/art.41042] [Citation(s) in RCA: 354] [Impact Index Per Article: 70.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/09/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel. RESULTS Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co-administration of low-dose methotrexate with TNFi is not recommended, nor is a strict treat-to-target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended. CONCLUSION These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.
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Affiliation(s)
- Michael M Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | | | | | | | - David Yu
- University of California, Los Angeles
| | | | - Nigil Haroon
- University of Toronto, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Runsheng Wang
- Columbia University Medical Center, New York, New York
| | - Ann Biehl
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | - Meika A Fang
- VA West Los Angeles Medical Center, Los Angeles, California
| | - Grant Louie
- Arthritis and Rheumatism Associates, Wheaton, Maryland
| | | | | | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
| | | | - Liron Caplan
- Rocky Mountain Regional VA Medical Center and University of Colorado, Aurora
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14
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Ward MM, Deodhar A, Gensler LS, Dubreuil M, Yu D, Khan MA, Haroon N, Borenstein D, Wang R, Biehl A, Fang MA, Louie G, Majithia V, Ng B, Bigham R, Pianin M, Shah AA, Sullivan N, Turgunbaev M, Oristaglio J, Turner A, Maksymowych WP, Caplan L. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Care Res (Hoboken) 2019; 71:1285-1299. [PMID: 31436026 DOI: 10.1002/acr.24025] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/09/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel. RESULTS Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co-administration of low-dose methotrexate with TNFi is not recommended, nor is a strict treat-to-target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended. CONCLUSION These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.
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Affiliation(s)
- Michael M Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | | | | | | | - David Yu
- University of California, Los Angeles
| | | | - Nigil Haroon
- University of Toronto, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Runsheng Wang
- Columbia University Medical Center, New York, New York
| | - Ann Biehl
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | - Meika A Fang
- VA West Los Angeles Medical Center, Los Angeles, California
| | - Grant Louie
- Arthritis and Rheumatism Associates, Wheaton, Maryland
| | | | | | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
| | | | - Liron Caplan
- Rocky Mountain Regional VA Medical Center and University of Colorado, Aurora
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15
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Zhu W, He X, Cheng K, Zhang L, Chen D, Wang X, Qiu G, Cao X, Weng X. Ankylosing spondylitis: etiology, pathogenesis, and treatments. Bone Res 2019; 7:22. [PMID: 31666997 PMCID: PMC6804882 DOI: 10.1038/s41413-019-0057-8] [Citation(s) in RCA: 193] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 05/20/2019] [Accepted: 05/23/2019] [Indexed: 02/06/2023] Open
Abstract
Ankylosing spondylitis (AS), a common type of spondyloarthropathy, is a chronic inflammatory autoimmune disease that mainly affects spine joints, causing severe, chronic pain; additionally, in more advanced cases, it can cause spine fusion. Significant progress in its pathophysiology and treatment has been achieved in the last decade. Immune cells and innate cytokines have been suggested to be crucial in the pathogenesis of AS, especially human leukocyte antigen (HLA)‑B27 and the interleukin‑23/17 axis. However, the pathogenesis of AS remains unclear. The current study reviewed the etiology and pathogenesis of AS, including genome-wide association studies and cytokine pathways. This study also summarized the current pharmaceutical and surgical treatment with a discussion of future potential therapies.
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Affiliation(s)
- Wei Zhu
- 1Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100730 Beijing, China
| | - Xuxia He
- 2Department of Clinical Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, 100730 Beijing, China
| | - Kaiyuan Cheng
- 1Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100730 Beijing, China
| | - Linjie Zhang
- 1Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100730 Beijing, China
| | - Di Chen
- 3Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL 60612 USA
| | - Xiao Wang
- 4Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD USA
| | - Guixing Qiu
- 1Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100730 Beijing, China
| | - Xu Cao
- 4Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD USA
| | - Xisheng Weng
- 1Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100730 Beijing, China
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16
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Uhrenholt L, Schlemmer A, Hauge EM, Christensen R, Dreyer L, Suarez-Almazor ME, Kristensen S. Dosage reduction and discontinuation of biological disease-modifying antirheumatic drugs in patients with rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis: protocol for a pragmatic, randomised controlled trial (the BIOlogical Dose OPTimisation (BIODOPT) trial). BMJ Open 2019; 9:e028517. [PMID: 31292181 PMCID: PMC6624054 DOI: 10.1136/bmjopen-2018-028517] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 05/16/2019] [Accepted: 06/14/2019] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The The BIOlogical Dose OPTimisation (BIODOPT) trial is a pragmatic, multicentre, randomised controlled, open-label, parallel-group, equivalence study designed to evaluate tapering of biological disease-modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) in sustained clinical remission or low disease activity (LDA). Traditionally, these patients maintain standard dosage of bDMARD lifelong; however, recent studies indicate that a significant proportion of patients in sustained remission or LDA can taper their bDMARD and maintain stable disease activity. Thus, this trial aims to evaluate whether a disease activity-guided tapering strategy for bDMARDs will enable a significant dosage reduction while maintaining disease activity compared with usual care. From the individual patient's standpoint as well as from a societal perspective, it would be advantageous if bDMARDs could be reduced or even discontinued while maintaining disease activity. METHODS AND ANALYSIS A total of 180 patients with RA, PsA or axSpA treated with bDMARDs and in clinical remission/LDA during the past 12 months will be enrolled from four centres in Denmark. Patients will be randomised in a ratio of 2:1 to either disease activity-guided tapering of bDMARDs (intervention group) or continuation of bDMARDs as usual care (control group).The primary objective is the difference between the two groups in the proportion of patients who have reduced their inclusion dosage of bDMARDs to 50% or less while maintaining stable disease activity at 18 months follow-up. ETHICS AND DISSEMINATION The study is approved by the ethics committee of Northern Jutland, Denmark (N-20170073) and by the Danish Medicine Agency. Patient research partner KHH contributed to refinement of the protocol and approved the final manuscript. Results will be disseminated through publication in international peer-reviewed journals. TRIAL REGISTRATION NUMBER 2017-001970-41; Pre-results.
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Affiliation(s)
- Line Uhrenholt
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Annette Schlemmer
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
| | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Lene Dreyer
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Maria E Suarez-Almazor
- Department of General Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Salome Kristensen
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
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17
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Park JW, Kim HA, Shin K, Park YB, Kim TH, Song YW, Lee EY. Effects of tapering tumor necrosis factor inhibitor on the achievement of inactive disease in patients with axial spondyloarthritis: a nationwide cohort study. Arthritis Res Ther 2019; 21:163. [PMID: 31272498 PMCID: PMC6611048 DOI: 10.1186/s13075-019-1943-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/14/2019] [Indexed: 12/17/2022] Open
Abstract
Objectives To investigate the association between the extent of tapering tumor necrosis factor inhibitor (TNFi) and the likelihood of achieving inactive disease in patients with axial spondyloarthritis (axSpA) Methods We analyzed 1575 1-year follow-up interval data of 776 axSpA patients treated with TNFi for more than 1 year in a nationwide observational cohort. The decision on tapering TNFi was made by patients and their physicians. We quantified TNFi used during interval as a dose quotient (DQ). The intervals were classified into the heavy-tapering (DQ < 50), mild-tapering (DQ 50–99), and control groups (DQ = 100). Outcome variables included achieving Ankylosing Spondylitis Disease Activity Score-inactive disease (ASDAS-ID) and major clinical response of Bath Ankylosing Spondylitis Disease Activity Index (BASDAI50) in the follow-up visit. The effects of TNFi tapering on the outcome were analyzed using the generalized estimating equation. Results At the baseline visit, 91.1% of the patients showed a high disease activity (ASDAS-CRP ≥ 2.1). DQ of each interval was significantly influenced by the ASDAS-CRP measure in the prior follow-up (P < 0.001). ASDAS-ID was observed in 42.3% of the intervals. A multivariable analysis showed that the likelihood of outcome achievement was comparable between the control and mild-tapering groups, but significantly decreased in the heavy-tapering group (vs. the control group, adjusted OR = 0.28, [95% CI, 0.08–0.94]). In contrast, the likelihood to achieve BASDAI50 response was not different among the groups. In the subgroup of patients who reached ASDAS-ID 1 year after TNFi treatment (n = 327), ASDAS-ID was observed in 66.1% of the subsequent intervals, and only the mild-tapering group showed a likelihood of target maintenance comparable with that of the control group (adjusted OR = 1.25 [0.41–3.80]). This likelihood decreased with an increase in ASDAS-CRP. Conclusion Mild tapering of TNFi has efficacy comparable with that of the standard-dose treatment for ASDAS-ID achievement in patients with axSpA. Electronic supplementary material The online version of this article (10.1186/s13075-019-1943-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Kichul Shin
- Division of Rheumatology, Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hwan Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
| | - Yeong Wook Song
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Eun Young Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
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18
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Lindström U, Olofsson T, Wedrén S, Qirjazo I, Askling J. Biological treatment of ankylosing spondylitis: a nationwide study of treatment trajectories on a patient level in clinical practice. Arthritis Res Ther 2019; 21:128. [PMID: 31138285 PMCID: PMC6540538 DOI: 10.1186/s13075-019-1908-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/07/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND There is substantial evidence that patients with ankylosing spondylitis (AS) have high response rates to tumour necrosis factor inhibitors (TNFi), a low likelihood of successful treatment termination, but yet a limited drug retention. Whereas several reports have assessed drug retention rates for TNFi in AS, there are few, if any, studies investigating the actual treatment trajectories on a patient level, including subsequent therapy changes and dose reductions, of individual patients. The aim of this study was to describe 5-year treatment trajectories in patients with ankylosing spondylitis (AS) starting a first TNFi. METHODS Bio-naïve patients with AS starting a TNFi in 2006-2015 were identified in the nationwide Swedish Rheumatology Quality register and followed until 31 December 2015. All changes in their anti-rheumatic treatment during follow-up were recorded. To further increase precision, these data were complimented by information on the amount of prescribed subcutaneous TNFi collected from pharmacies during each year, retrieved from the Swedish Prescribed Drug Register. RESULTS Two thousand five hundred ninety patients started a first TNFi 2006-2015, and after 1 year, 74% remained on their first TNFi. However, after 5 years, this figure was only 46%, although at that time 63% were still on treatment with any biologic, while 30% had no anti-rheumatic treatment at all. After discontinuing the first TNFi, 46% switched directly to a second TNFi, but the drug retention for the second and third TNFi grew successively shorter compared to that for the first TNFi. In contrast, patients remaining on treatment with their first subcutaneous TNFi gradually reduced the dose, so that during the fifth year of treatment only 66% had collected ≥ 75% of the defined daily doses for that year. CONCLUSION Less than half of patients with AS will remain on their first TNFi after 5 years, but most are still on a biologic. While patients remaining on treatment with their first TNFi appear to be able to reduce the dose over time, a large proportion cycle through several biologics, and 1/3 have no anti-rheumatic treatment after 5 years. This indicates the importance of thorough follow-up programs as well as a need for alternative therapeutic options.
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Affiliation(s)
- Ulf Lindström
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Tor Olofsson
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Sara Wedrén
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ilia Qirjazo
- Rheumatology Department, Linköping University Hospital, Linköping, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinical Epidemiology Unit, Karolinska University Hospital Solna, Stockholm, Sweden
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Li KP, Jin JY, Yang JS, Li Y, Zhao W, Luo G, Zhu J, Zhang JL, Huang F. Full dose, half dose, or discontinuation of etanercept biosimilar in early axial spondyloarthritis patients: a real-world study in China. Arch Med Sci 2019; 15:700-705. [PMID: 31110537 PMCID: PMC6524190 DOI: 10.5114/aoms.2018.76141] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/07/2018] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION To investigate the effect of dose maintenance, reduction, or discontinuation of the etanercept biosimilar Yisaipu (YSP) on early axial spondyloarthritis (axSpA) patients in remission with YSP 50 mg once weekly (QW). MATERIAL AND METHODS Patients were enrolled in three groups: full dose (YSP50), half dose (YSP25), and discontinuation (YSP0). Patients were assessed by the same rheumatologist every 8 weeks for 48 weeks. The primary endpoint was the proportion of non-failure patients in each group. If a flare occurred during the study period, the patient resumed YSP 50 mg QW or was switched to another tumor necrosis factor inhibitor. RESULTS A total of 144 patients were included and each group included 48 patients. The proportion of non-failure patients was significantly greater in the YSP50 group than in the YSP0 group at 48 weeks (91.7% vs. 72.9%, p = 0.032). The difference in the other two comparisons was not statistically significant (YSP50 vs. YSP25 group, p = 0.522; YSP25 vs. YSP0 group, p = 0.132). The median time to flare did not differ significantly between the three groups (p > 0.05). Most patients who flared regained remission rapidly after resuming YSP 50 mg QW or starting adalimumab 40 mg every other week. CONCLUSIONS For patients with early axSpA in remission on YSP for more than 12 weeks, continuation of YSP at full dose was superior to discontinuation of YSP, but not superior to halving the dose.
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Affiliation(s)
- Kun-Peng Li
- Department of Rheumatology, Chinese PLA General Hospital, Beijing, China
| | - Jing-Yu Jin
- Department of Rheumatology, Chinese PLA General Hospital, Beijing, China
| | - Jin-Shui Yang
- Department of Rheumatology, Chinese PLA General Hospital, Beijing, China
| | - Yan Li
- Department of Rheumatology, Chinese PLA General Hospital, Beijing, China
| | - Wei Zhao
- Department of Rheumatology, Chinese PLA General Hospital, Beijing, China
| | - Gui Luo
- Department of Rheumatology, Chinese PLA General Hospital, Beijing, China
| | - Jian Zhu
- Department of Rheumatology, Chinese PLA General Hospital, Beijing, China
| | - Jiang-Lin Zhang
- Department of Rheumatology, Chinese PLA General Hospital, Beijing, China
| | - Feng Huang
- Department of Rheumatology, Chinese PLA General Hospital, Beijing, China
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González-Álvaro I, Blasco AJ, Lázaro P, Sánchez-Piedra C, Almodovar R, Bachiller-Corral J, Balsa A, Caliz R, Candelas G, Fernández-Carballido C, García-Aparicio A, García-Magallón B, García-Vicuña R, Gómez-Centeno A, Ortiz AM, Sanmartí R, Sanz J, Tejera B. REDOSER project: optimising biological therapy dose for rheumatoid arthritis and spondyloarthritis patients. Heliyon 2017; 3:e00452. [PMID: 29264411 PMCID: PMC5727544 DOI: 10.1016/j.heliyon.2017.e00452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/01/2017] [Accepted: 11/06/2017] [Indexed: 11/16/2022] Open
Abstract
Background Reducing the dose of biological therapy (BT) when patients with immune-mediated arthritis achieve a sustained therapeutic goal may help to decrease costs for national health services and reduce the risk of serious infection. However, there is little information about whether such a decision can be applied universally. Therefore, the objective of this study was to develop appropriateness criteria for reducing the dose of BT in patients with rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), and peripheral spondyloarthritis (pSpA). Methods The RAND/UCLA appropriateness method was coordinated by experts in the methodology. Five rheumatologists with clinical research experience in RA and/or SpA selected and precisely defined the variables considered relevant when deciding to reduce the dose of BT in the 3 diseases, in order to define patient profiles. Ten rheumatologists with experience in prescribing BT anonymously rated each profile on a scale of 1 (completely inappropriate) to 9 (completely appropriate) after revising a summary of the evidence obtained from 4 systematic literature reviews carried out specifically for this project. Findings A total of 2,304 different profiles were obtained for RA, 768 for axSpA, and 3,072 for pSpA. Only 327 (14.2%) patient profiles in RA, 80 (10.4%) in axSpA, and 154 (5%) in pSpA were considered appropriate for reducing the dose of BT. By contrast, 749 (32.5%) patient profiles in RA, 270 (35.3%) in axSpA, and 1,243 (40.5%) in pSpA were considered inappropriate. The remaining profiles were considered uncertain. Interpretation Appropriateness criteria for reducing the dose of BT were developed in 3 inflammatory conditions. These criteria can help clinicians treating these disorders to optimize the BT dose. However, further research is needed, since more than 50% of the profiles were considered uncertain and the real prevalence of each profile in daily clinical practice remains unknown.
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Affiliation(s)
- Isidoro González-Álvaro
- Rheumatology Service, Hospital Universitario La Princesa, IIS-IP, c/Diego de León 62, Madrid 28006, Spain
- Corresponding author.
| | | | - Pablo Lázaro
- Independent Health Services Researcher, Madrid, Spain
| | - Carlos Sánchez-Piedra
- Research Unit, Spanish Society of Rheumatology, c/Marques del Duero 5, Madrid 28001, Spain
| | - Raquel Almodovar
- Rheumatology Section, Hospital Universitario Fundación Alcorcón, c/Budapest 1, Alcorcón 28922, Spain
| | - Javier Bachiller-Corral
- Rheumatology Service, Hospital Universitario Ramon y Cajal, C/Colmenar Viejo km 9.1, Madrid 28034, Spain
| | - Alejandro Balsa
- Rheumatology Service, Hospital Univeritario La Paz, IdIPaz, Paseo de la Castellana 261, Madrid 28046, Spain
| | - Rafael Caliz
- Rheumatology Service, Hospital Universitario Virgen de la Nieves, Avenida de las Fuerzas Armadas 2, Granada 18014, Spain
| | - Gloria Candelas
- Rheumatology Service, Hospital Clínico San Carlos, IdISSC, c/Profesor Martin Lagos s/n, Madrid 28040, Spain
| | | | - Angel García-Aparicio
- Rheumatology Service, Hospital Virgen de la Salud, Avda de Barber 30, Toledo 45004, Spain
| | - Blanca García-Magallón
- Rheumatology Unit, Hospital General San Jorge, Avda Martinez Velasco 36, Huesca 22004, Spain
| | - Rosario García-Vicuña
- Rheumatology Service, Hospital Universitario La Princesa, IIS-IP, c/Diego de León 62, Madrid 28006, Spain
| | - Antonio Gómez-Centeno
- Rheumatology Service, Hospital Universitario Parc Taulí, Parc Taulí 1, Sabadell 08208, Spain
| | - Ana M. Ortiz
- Rheumatology Service, Hospital Universitario La Princesa, IIS-IP, c/Diego de León 62, Madrid 28006, Spain
| | - Raimon Sanmartí
- Rheumatology Service, Hospital Clinic, c/Villarroel 170, Barcelona 08036, Spain
| | - Jesús Sanz
- Rheumatology Service, Hospital Universitario Puerta de Hierro, c/Manuel de Falla 1, Majadahonda 28222, Spain
| | - Beatriz Tejera
- Rheumatology Service, Hospital Universitario de Canarias, C/Ofra s/n, Santa Cruz de Tenerife 38320, Spain
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Sepriano A, Regel A, van der Heijde D, Braun J, Baraliakos X, Landewé R, Van den Bosch F, Falzon L, Ramiro S. Efficacy and safety of biological and targeted-synthetic DMARDs: a systematic literature review informing the 2016 update of the ASAS/EULAR recommendations for the management of axial spondyloarthritis. RMD Open 2017; 3:e000396. [PMID: 28176964 PMCID: PMC5278329 DOI: 10.1136/rmdopen-2016-000396] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 12/03/2016] [Accepted: 12/09/2016] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To update the evidence for the efficacy and safety of (b)biological and (ts)targeted-synthetic disease-modifying anti-rheumatic drugs (DMARDs) in patients with axial spondyloarthritis (axSpA) to inform the 2016 update of the Assessment of SpondyloArthritis international Society/European League Against Rheumatism (ASAS/EULAR) recommendations for the management of axSpA. METHODS Systematic literature review (2009-2016) for randomised controlled trials (RCT), including long-term extensions, strategy trials and observational studies (the latter was only for safety assessment and a comparator was required). Interventions were any bDMARD or tsDMARD. All relevant efficacy and safety outcomes were included. RESULTS 76 papers and 24 abstracts fulfilled the inclusion criteria. Large treatment effects were found both in radiographic axSpA (r-axSpA) and non-radiographic axSpA (nr-axSpA) for all tumour necrosis factor inhibitors (TNFi) (NNT to achieve ASAS40 response ranged between 2.6-5.2 for r-axSpA and 2.3-5.4 for nr-axSpA). For nr-axSpA, efficacy was superior for those who had objective signs of inflammation (positive C reactive protein or inflammation on MRI-SI). Secukinumab 150 mg has shown efficacy in two phase 3 RCTs (NNT to achieve ASAS40 response: 3.4 and 4.0). Ustekinumab and tofacitinib have shown positive results in phase 2/proof-of-concept trials; trials with apremilast, rituximab, interleukin (IL)-6 antagonists and abatacept have failed their primary end points. New (unknown) safety signals were not found in the trials but long-term observational safety data for TNFi are still scarce. CONCLUSIONS New evidence supports the efficacy and safety of TNFi both in r-axSpA and nr-axSpA. Secukinumab is the first drug targeting the IL-17 pathway in r-axSpA that has shown efficacy.
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Affiliation(s)
- Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Andrea Regel
- Rheumazentrum Ruhrgebiet, Ruhr-University Bochum, Herne, Germany
| | | | - Jürgen Braun
- Rheumazentrum Ruhrgebiet, Ruhr-University Bochum, Herne, Germany
| | | | - Robert Landewé
- Department of Clinical Immunology & Rheumatology, Amsterdam Rheumatology & Clinical Immunology Center, Amsterdam, The Netherlands
- Zuyderland Medical Center, Heerlen, The Netherlands
| | | | - Louise Falzon
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, USA
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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Navarro-Compán V, Plasencia-Rodríguez C, de Miguel E, Balsa A, Martín-Mola E, Seoane-Mato D, Cañete JD. Anti-TNF discontinuation and tapering strategies in patients with axial spondyloarthritis: a systematic literature review. Rheumatology (Oxford) 2016; 55:1188-94. [PMID: 26998860 DOI: 10.1093/rheumatology/kew033] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE The aim was to evaluate whether anti-TNF discontinuation and tapering strategies are efficacious for maintaining remission or low disease activity (LDA) in patients with axial spondyloarthritis. METHODS A systematic literature review up to September 2014 was performed using Medline, EMBASE and Cochrane databases. Longitudinal studies evaluating the efficacy of discontinuation/tapering of anti-TNF therapy to maintain clinical response achieved after receiving a standard dose of the same drug were included. The results were grouped according to the type of strategy (discontinuation or tapering) evaluated. RESULTS Thirteen studies out of 763 retrieved citations were included. Overall, published data are scarce and the level of evidence of the studies is weak. Five studies provided evidence for assessing discontinuation strategy. The frequency of patients developing flare during the follow-up period ranged between 76 and 100%. The median (range) follow-up period was 52 (36-52) weeks and time to flare 16 (6-24) weeks. Additionally, eight studies evaluating tapering strategy were selected. The percentage of patients maintaining LDA or remission was reported in five studies and ranged between 53 and 100%. The remaining three studies reported the mean change in BASDAI and CRP after reducing the anti-TNF dose and did not observe any relevant increase in these parameters. CONCLUSION Published data indicate that a tapering strategy for anti-TNF therapy is successful in maintaining remission or LDA in most patients with axial spondyloarthritis. However, a discontinuation strategy is not recommended because it leads to flare in most cases. Further studies with an appropriate design covering the whole spectrum of the disease are required to confirm these results.
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Affiliation(s)
| | | | | | | | | | | | - Juan D Cañete
- Department of Rheumatology, Hospital Clinic and IDIBAPS, Barcelona, Spain
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23
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Cui Y, Zheng J, Zhang X, Zeng H, Luo R. Evaluation of treatments for sacroiliitis in spondyloarthropathy using the Spondyloarthritis Research Consortium Canada scoring system. Arthritis Res Ther 2016; 18:38. [PMID: 26832154 PMCID: PMC4734856 DOI: 10.1186/s13075-016-0916-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 01/04/2016] [Indexed: 11/10/2022] Open
Abstract
Background In this study, the Spondyloarthritis Research Consortium Canada (SPARCC) scoring method was used to compare treatment methods in patients with axial spondyloarthritis (SpA), a form of sacroiliitis. MRI abnormalities in bone marrow edema (BME) were compared before and after treatment in order to compare the efficacy of anti-TNF-α and DMARD, alone or in combination, as treatments for sacroiliitis. Methods Fifty-six Chinese patients with axial SpA (mean age 22.6 years) were recruited. Patients were divided into three groups according to different treatments (anti-TNF-α alone vs. DMARDs alone vs. combined anti-TNF-α and DMARDs). MRI examinations were performed before and after treatment. The SPARCC score, clinically relevant AS Disease Activity (ASDAS) indices, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were analyzed. Results After treatment, ASDAS and SPARCC scores, ESR, and CRP were significantly improved (P < 0.05) in the anti-TNF-α monotherapy and combination groups; however, there were no statistically significant differences (P > 0.05) in clinical disease activity and radiological inflammation of sacroiliac joint (SIJ) in patients in the DMARDs alone group. SPARCC showed a correlation with ASDAS score pre-treatment, but not post-treatment. Furthermore, there were significant changes (P < 0.05) in these patients with axial SpA after only 3 months of treatment. Follow-up studies of patients who continued therapy for 4-6 months and 9-12 months revealed statistically significant differences from baseline (P < 0.05). Conclusions SPARCC can be used to assess severity of disease pre-treatment. Anti-TNF-α treatment resulted in effective reduction of disease activity and BME of SIJ after 3 months of therapy.
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Affiliation(s)
- Yang Cui
- Department of Rheumatism, Guangdong General Hospital, No. 106, Zhongshaner Road, Guangzhou, China.
| | - Jinping Zheng
- Department of Rheumatism, Guangdong General Hospital, No. 106, Zhongshaner Road, Guangzhou, China.
| | - Xiao Zhang
- Department of Rheumatism, Guangdong General Hospital, No. 106, Zhongshaner Road, Guangzhou, China.
| | - Hui Zeng
- Medical Imaging Centre, Guangdong General Hospital, Guangzhou, 510010, China.
| | - Riqiang Luo
- Department of Rheumatism, Guangdong General Hospital, No. 106, Zhongshaner Road, Guangzhou, China.
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Almirall M, Salman-Monte TC, Lisbona MP, Maymó J. Dose reduction of biological treatment in patients with axial spondyloarthritis in clinical remission: Are there any differences between patients who relapsed and to those who remained in low disease activity? Rheumatol Int 2015; 35:1565-8. [PMID: 25994091 DOI: 10.1007/s00296-015-3288-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 05/12/2015] [Indexed: 01/17/2023]
Abstract
The aim of the study was to assess whether dose reduction of biological treatment in patients with axial spondyloarthritis in sustained remission could be effective to maintain remission or low disease activity at 1 year and to explore baseline differences between patients who remained in remission or low disease activity and patients who relapsed. This was a prospective, observational study. All consecutive patients with axial spondyloarthritis in sustained remission were included and received low doses of anti-TNF-α according to a dose reduction protocol. At 1 year, the percentage of patients in remission or low disease activity and in relapse and the differences in baseline characteristics between the two groups were calculated. Of forty-two patients, 76.2 % remained in remission or low disease activity at 1 year. A significant shorter duration of remission before dose reduction, shorter duration of biological treatment and shorter disease duration were observed in the relapse group. Most of our patients with axial spondyloarthritis remained in remission or low disease activity at 1 year after dosage reduction of biologics and shorter duration of remission, shorter duration of biological treatment and shorter disease duration discriminated the patients who relapsed.
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Affiliation(s)
- Miriam Almirall
- Department of Rheumatology, Parc de Salut Mar, Universidad Autónoma de Barcelona, Passeig Marítim 25-29, 08003, Barcelona, Spain,
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Baraliakos X, Deodhar A. Unanswered questions in the management of axial spondyloarthritis: an opinion piece. Clin Rheumatol 2014; 33:1359-65. [PMID: 24941929 DOI: 10.1007/s10067-014-2740-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Senabre-Gallego JM, Santos-Ramírez C, Santos-Soler G, Salas-Heredia E, Sánchez-Barrioluengo M, Barber X, Rosas J. Long-term safety and efficacy of etanercept in the treatment of ankylosing spondylitis. Patient Prefer Adherence 2013; 7:961-72. [PMID: 24101863 PMCID: PMC3790868 DOI: 10.2147/ppa.s33109] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
To date, anti-tumor necrosis factor alfa (anti-TNF-α) therapy is the only alternative to nonsteroidal anti-inflammatory drugs for the treatment of ankylosing spondylitis. Etanercept is a soluble TNF receptor, with a mode of action and pharmacokinetics different to those of antibodies and distinctive efficacy and safety. Etanercept has demonstrated efficacy in the treatment of ankylosing spondylitis, with or without radiographic sacroiliitis, and other manifestations of the disease, including peripheral arthritis, enthesitis, and psoriasis. Etanercept is not efficacious in inflammatory bowel disease, and its efficacy in the treatment of uveitis appears to be lower than that of other anti-TNF drugs. Studies of etanercept confirmed regression of bone edema on magnetic resonance imaging of the spine and sacroiliac joint, but failed to reduce radiographic progression, as do the other anti-TNF drugs. It seems that a proportion of patients remain in disease remission when the etanercept dose is reduced or administration intervals are extended. Etanercept is generally well tolerated with an acceptable safety profile in the treatment of ankylosing spondylitis. The most common adverse effect of etanercept treatment is injection site reactions, which are generally self-limiting. Reactivation of tuberculosis, reactivation of hepatitis B virus infection, congestive heart failure, demyelinating neurologic disorders, hematologic disorders like aplastic anemia and pancytopenia, vasculitis, immunogenicity, and exacerbation or induction of psoriasis are class effects of all the anti-TNF drugs, and have been seen in patients with ankylosing spondylitis. However, etanercept is less likely to induce reactivation of tuberculosis than the other anti-TNF drugs and it has been suggested that etanercept might be less immunogenic, especially in ankylosing spondylitis. Acute uveitis, Crohn's disease, and sarcoidosis are other adverse events that have been rarely associated with etanercept therapy in patients with ankylosing spondylitis.
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Affiliation(s)
| | | | | | | | - Mabel Sánchez-Barrioluengo
- INGENIO (Instituto de Gestión de la Inovación y del Conocimiento) (CSIC [Consejo Superior de Investigaciones Científicas]-UPV [Universidad Politécnica de Valencia]), Universitat Politècnica de València, Valencia, Spain
| | - Xavier Barber
- CIO (Centro de Investigación Operativa)-UMH (Universidad Miguel Hernández), Universidad Miguel Henández, Elche, Spain
| | - José Rosas
- Rheumatology, Hospital Marina Baixa, Villajoyosa, Spain
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