Decreasing TNFi Dose Maintains Stable Rheumatoid Arthritis Disease Activity

Successful clinical response to treatment with tumor necrosis factor inhibitor (TNFi) was maintained even during reduced dosages in patients with rheumatoid arthritis (RA), according to findings presented at the European League Against Rheumatism Annual Congress (EULAR 2015) annual meeting in June in Rome, Italy.

Researchers from the Department of Rheumatology, King's College Hospital NHS Foundation Trust, UK studied RA patients being treated with TNFi (either etanercept or adalimumab) for 12 months across various treatment centers in order to determine whether or not exacerbations of signs and symptoms could be maintained or reduced with reductions in TNFi doses and receiving disease modifying anti-rheumatic drug (DMARD) treatment.

Patients enrolled in the study displayed stable low disease activity (had a disease activity score (DAS) 28 score of less than 3.2) for more than three months. Excluded patients included those who had serious concomitant illnesses or those who were taking high dose steroids (defined as more than 10 mg daily prednisolone).

“The optimal management of RA involves achieving the lowest possible disease activity — ideally remission, and then maintaining this level of control,” lead author, Dr. James Galloway, explained in a press release. “Findings from our study have shown that adopting a TNFi dose reduction strategy can still meet this objective, with no compromise on symptom control for the patient and offering a more cost effective option by substantially reducing the high drug costs associated with TNFi maintenance therapy.”

For the first six months of observation, 14 percent of patients who remained on their TNFi dose experienced exacerbations, compared to 13 percent of patients whose doses were reduced by a third. The researchers wrote that a two thirds reduction increased the odds of an exacerbation occurring by four times, compared to the group with a one third TNFi dose reduction. Flares occurred in just about a third of those patients (37 percent).

In total, 47 patients reduced their TNFi doses, then stopped TNFi after six months. About half (45 percent) went through the process without experiencing exacerbation. Those patients’ final mean DAS 28 score after stopping treatment was 2.2, which the researchers thought demonstrated low disease activity.

There were not any significant differences in either medication dose reduction group in terms of self reported measures of disability (extrapolated from the Health Assessment Questionnaire score), the authors said, and post dose reduction flares resolved when the patients resumed normal doses.