Author: Laura Cowen
medwireNews: A tapering treat-to-target (T2T) strategy can lead to a large reduction in tumor necrosis factor (TNF) inhibitor dose without impacting disease control in people with psoriatic arthritis (PsA) or axial spondyloarthritis (axSpA), study findings indicate.
Celia Michielsens (Sint Maartenskliniek, Nijmegen, the Netherlands) and co-investigators say that although T2T tapering strategies can reduce the drawbacks associated with TNF inhibitor use, such as infection risk, patient burden, and cost, there is currently no high-quality evidence on this approach in people with PsA or axSpA.
To address this, they randomly assigned 122 patients with PsA (n=64) or axSpA (n=58) using a TNF inhibitor with at least 6 months of stable low disease activity (LDA) to receive treatment with a disease activity-guided T2T strategy with (PsA, n=42; axSpA, n=39) or without tapering (PsA, n=22; axSpA, n=19).
Patients in the tapering group reduced their TNF inhibitor dose in a stepwise manner from 100% to 66% and 50% until discontinuation during each 3-monthly visit where LDA was maintained. Patients in the no-tapering group continued their original TNF inhibitor dose or interval throughout the 12-month study.
For PsA, LDA was defined as a PASDAS of 3.2 points or lower and modified body surface area involvement at or below 3%, while LDA for axSpA was defined as an ASDAS below 2.1 points.
Michielsens and co-authors report in the Annals of the Rheumatic Diseases that, at 12 months, the proportion of patients with LDA was 69% in the tapering group and 73% in the no-tapering group, with the adjusted difference of 5% falling within the non-inferiority margin of 20%.
In addition, the mean percentage of daily defined dose at 12 months was 53% with tapering versus 91% without tapering.
At 12 months, 72% patients in the tapering group remained on a tapered dose, including 28% who had completely discontinued their TNF inhibitor.
There was no significant difference between the two groups in the cumulative incidence of flare, occurring in 85% and 78% of the tapering and no-tapering groups, respectively.
There was also no significant difference in adverse event rates or quality of life between the two arms, but the initiation or escalation of concomitant medication was more common in the tapering group than in the no-tapering group, with a significant difference observed for NSAID use (54 vs 24%).
Michielsens et al say: “Our results indicate that a T2T tapering strategy is an effective and safe alternative to a T2T full dose continuation strategy in patients with PsA and axSpA with stable LDA using TNF [inhibitors].”
They add: “Implementing T2T tapering strategies into practice will reduce TNF [inhibitor] use, and thereby patient burden, risk for adverse events and costs, while maintaining disease control.”
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