ACR 2018: Pros and Cons of TNF Inhibitor Tapering in Axial Spondyloarthritis


Findings from the first study to incorporate a meta-analysis on TNFi dose adjustment in an axSpA population.

doctor woman physician x-ray spondyloarthritis ACR

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Patients with axial spondyloarthritis (axSpA) who have achieved stable disease might experience little benefit or harm from the withdrawal or reduction of tumor necrosis factor inhibitor (TNFi) therapy, according to a systematic review and meta-analysis presented at the 2018 American College of Rheumatology (ACR)/Association of Rheumatology Health Professionals (ARHP) Annual Meeting in Chicago, Illinois.

Axial spondyloarthritis is an umbrella term, which includes ankylosing spondylitis (AS) as well as patients with axial inflammation who do not have x-ray changes suggestive of structural damage that currently define AS. Patients with axSpA who have achieved a stable disease state and are being treated with TNFi therapy may wish to opt for dose reduction, but lowering the standard dosing regimen presents several potential risks including disease relapse.

This study investigated the efficacy of reducing or withdrawing the standard TNFi dose for the treatment of axSpA. The results were presented at a Poster Session at the ACR/ARHP annual meeting on October 21 by Daeria O. Lawson of the Department of Rheumatology at Toronto Western Hospital in Ontario.

The study
For this systematic review and meta-analysis, CENTRAL, Embase, and MEDLINE databases were searched through February 2018, along with trial registries and reference lists of relevant articles. A total of 297 full-texts were reviewed for eligibility, and six randomized controlled trials were included in the meta-analysis.

Data were pooled using a random-effects model for the following outcomes: Assessment of SpondyloArthritis International Society 40% (ASAS40) improvement criteria, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), C-reactive protein (CRP), remission, relapse, and quality of life (QoL).

Next: the findings-and their implications for physicians.

The findings
The study found higher ASAS40 rates with standard TNFi treatment as compared with an adjusted dose, with data from 538 participants resulting in a risk ratio of 0.63. Researchers found no differences in the mean BASDAI (mean difference, 0.40; 319 participants) and mean CRP (mean difference, 0.68; 319 participants) between the standard and adjusted doses.

There were higher rates of remission in the standard dose as compared with the adjusted dose, with 694 participants resulting in a risk ratio of 0.65. There were fewer events of disease relapse in the standard versus adjusted dose, with 156 participants, resulting in a risk ratio of 1.20. QoL was not pooled because of clinical heterogeneity.

Implications for physicians
This study is the first review to incorporate a meta-analysis on TNFi dose adjustment in an axSpA population. Overall, the researchers found that patients with axSpA who have achieved stable disease might experience little benefit or harm from TNFi withdrawal or reduction. However, the risk/benefit ratio of withdrawing treatment is still unclear based on current published data. Individualizing this decision is an important research question for future studies.


Lawson DO, Eraso M, Mbuagbaw L, et al. TNF Inhibitor Dose Tapering in Axial Spondyloarthritis: A Systematic Review and Meta-Analysis [Abstract 692]. Arthritis Rheumatol. 2018;70(suppl 10). Accessed October 22, 2018.

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