TNFi Dose Reduction Shows No Benefit for Spondyloarthritis


A new study shows there is little to no clinical benefit in reducing TNFi treatment dosages for patients with axial spondyloarthritis (axSpA).

A new study shows there is little to no clinical benefit in reducing TNFi treatment dosages for patients with axial spondyloarthritis (axSpA).

“Maintaining the standard dose probably improves the sustained effect on disease activity and helps to prevent disease flare,” write Daeria O. Lawson, CCRP, and colleagues in the March 12 online issue of Arthritis Care and Research.

The researchers, of McMaster University in Ontario, conducted a systematic review and meta-analysis of six randomized controlled trials of 442 patients with ankylosing spondylitis and 305 with non-radiographic axSpA (nr-axSpA). They found that fewer patients on the reduced dose regimen achieved ASAS40 and ASAS partial remission, as compared to patients who continued to receive standard doses.

Patients in the reduced dose group experienced an increase in the Bath Ankylosing Spondylitis Disease Activity Index score, but no difference in C-reactive protein levels. They also experienced more disease flares and relapses (risk ratio 1.73). However, there were no differences in infection rates or injection site reactions.

Tumor necrosis factor inhibitors (TNFi) are a core treatment of spondyloarthritis. They are recommended for patients with axial disease or as a follow-up treatment to nonsteroidal anti-inflammatory drugs (NSAIDs) in non-responders.

But once a patient achieves remission, there is no one consensus in terms of whether patients should be tapered off TNFi therapy or continue to take the full dose. Findings from randomized controlled trials and cohort studies suggest that patients with active and stable disease could maintain remission or low disease activity with a lesser dose. However, which patients should undergo dose reductions has not been extensively studied.

RELATED:  "Long-Term TNFi Use in Axial Spondyloarthritis May Slow Radiographic Progression"

“Our findings confirm previous studies where standard TNFi doses suggest some benefit for disease activity and are more efficacious for achieving and maintaining stable disease. Interestingly, there were no discernable group differences for general measures of safety including rates of infection,” the authors wrote.

Due to the lack of clinical evidence and treatment guidelines, the authors suggest that physicians and patients make decisions about tapering treatment together, based on the individual needs of the patient.

“Given the growing body of evidence on this topic, future evidence syntheses should also incorporate network meta-analyses, which allow for the comparison of multiple interventions and combinations,” the authors wrote.


Daeria O. Lawson,  Maria Eraso, Lawrence Mbuagbaw,  Marianinha Joanes,  Theresa Aves,  Alvin Leenus,  Ahmed Omar,  Robert D. Inman. "Tumour necrosis factor inhibitor dose reduction for axial spondyloarthritis: A systematic review and meta‐analysis of randomized controlled trials,"Arthritis Care and Research. March 12, 2020.

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