Support for continuing methotrexate after tocilizumab withdrawal in RA patients
medwireNews: Two-year results from the SURPRISE study show that continued methotrexate treatment is associated with a higher likelihood of maintaining low disease activity among patients with rheumatoid arthritis (RA) who stop tocilizumab treatment after achieving remission.
The study, which was presented at the EULAR 2018 meeting in Amsterdam, the Netherlands, and published in the Annals of the Rheumatic Diseases, “has proved that more than half of patients would remain in low disease activity after discontinuing tocilizumab with continued methotrexate,” lead author Yuko Kaneko (Keio University School of Medicine, Tokyo, Japan) told medwireNews.
“It is a new, relevant finding because tocilizumab has been believed to be difficult to stop” without the use of conventional DMARDs, he added.
Kaneko and team randomly assigned 233 patients with active RA despite methotrexate treatment to receive add-on tocilizumab treatment or to switch from methotrexate to tocilizumab for 1 year. After this time, the 105 patients who achieved remission (Disease Activity Score at 28 joints [DAS28]<2.6 points) discontinued tocilizumab; participants receiving methotrexate treatment during the first year continued to do so for an additional year, whereas those who were previously treated with tocilizumab alone received no DMARDs for the second year of the study. Patients who experienced flares during this time were given tocilizumab and/or methotrexate.
The researchers found that a significantly higher proportion of patients who continued to receive methotrexate after tocilizumab withdrawal remained tocilizumab-free at the 2-year follow-up compared with those who received no DMARDs, at 67.3% versus 28.5%.
Moreover, methotrexate-treated patients were significantly more likely than those receiving no DMARDs to have low disease activity (DAS28≤3.2 points) in the absence of tocilizumab at 2 years, with rates of 55% versus 27%. Tocilizumab-free remission rates were also numerically higher among patients in the methotrexate group, but the difference did not reach statistical significance.
Although the study results indicate that “retaining methotrexate is better for maintaining low disease activity,” the study authors caution that continued methotrexate was associated with a higher rate of adverse events, particularly gastrointestinal symptoms, “which was a definite drawback” of the strategy.
A total of 18.4% of patients in the methotrexate group experienced gastrointestinal symptoms during the second year of the study, compared with none in the DMARD-free group.
Looking to the future, Kaneko said that “what kinds of patients can stop tocilizumab [while] remaining in remission, and whether stopping methotrexate with continued tocilizumab is feasible, are other clinical questions to be solved.”
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