Background/Purpose: Reducing the dose of biological therapy may be possible for patients with rheumatoid arthritis (RA) who have achieved remission or low disease activity (LDA).  However, patients in clinical remission may have synovitis detectable by ultrasound (US) and continue to accrue damage. We aimed to develop a strategy using both clinical and US assessment in a biologics review clinic to increase the likelihood of selecting the correct patients for biological therapy dose reduction, thereby minimising the chance of damage in those with subclinical synovitis.

Methods: All patients with RA (ACR criteria) receiving biologic therapies were reviewed in a biologics review clinic. At each appointment, patients underwent DAS28 assessment and US of their MCPs, PIP(2-5) and wrist joints (Esoate Mylab70). Synovitis was detected by power doppler (PDUS) and scored on a 0-3 semi-quantitative scale. PDUS remission was defined as a score of 0. Patients in clinical and US remission (DAS28<2.6 & PDUS=0) had the dose of anti-TNF therapy reduced by a third (adalimumab (ADA) to 40mg 3 weekly, etanercept (ETN) to 50mg every 10 days, infliximab (INF) reduced to 2mg/kg per infusion, certolizumab (CZB) reduced to 200mg every 3  weeks, golimumab (GOL) reduced to 50mg every 6 weeks). Patients were followed-up and if disease flared they were advised to ring a helpline to arrange an urgent clinic visit where a repeat DAS28 and US assessments were performed, and if needed the dose was increased back to baseline.

Results: 321 RA patients attended the clinic. All had fulfilled local requirements for biological therapy eligibility (including DAS28>5.1, and failed ³2 non-biological DMARDs). Baseline demographics showed mean age 59.4 years, 75.4% female, mean time from diagnosis to first biological therapy 10.8years, mean pre-biologic DAS28 5.69, baseline biologic ADA 112, ETN 58, INF 41, GOL 5, CZB 5, rituximab 73, tocilizumab 25, abatacept 2. 179(55.8%) patients were receiving their first biological, 197(61.4%) received a biologic & methotrexate in combination.

101(31.5%) patients were in DAS28 remission and 45(15%) were in LDA. PDUS remission was present in 42.9% and of those in clinical remission 69(72.6%) had a PDUS score of 0. Biological reduction was agreed by 56(81.2%) patients and of these, 42(75%) have remained on a reduced dose at a mean of 8.7 months. 14 patients have flared and returned to baseline treatment at a mean of 5.9 months.  Of patients flaring DAS28 score increased by mean 0.6. 11(78.6%) had a DAS28>2.6 and 50% had a PDUS=0.

Conclusion: A strategy using clinical assessment and US may increase the likelihood of correctly selecting patients with RA who could successfully reduce the dose of their biological therapy whilst maintaining clinical and ultrasound remission. This strategy may minimize the risk of ongoing joint damage in those who reduce therapy.

---

« Back to 2013 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/a-strategy-for-selecting-individuals-with-ra-for-reduction-of-anti-tnf-therapy-using-combined-clinical-and-ultrasound-assessment/