Background/Purpose: Remission in Psoriatic Arthritis, defined as a period of at least 3 consecutive visits with  no actively inflamed joints, occurs in about 17 percent of patients with PsA. Achieving a state of Minimal Disease Activity (MDA) can lead to reduction in joint damage progression. In clinical practice, we face a dilemma in terms of future management when a patient achieves MDA while being on anti-TNF therapy. The aim of this study was to identify and describe PsA patients who discontinued or reduced the dose of anti-TNF agent and continued to remain in a state of MDA.

Methods: Patients were identified from a large single centre psoriatic arthritis cohort. We included patients who achieved MDA (according to slightly modified criteria proposed by Coates et al) and discontinued their anti-TNF treatment or reduced the dose and continued to remain in MDA. No predetermined protocol was used for dose reduction and in most cases it was left to patient preference. MDA was defined when fulfilling at least 5 of the 7 following outcome measures: tender joint count ≤1; swollen joint count ≤1; psoriasis activity and severity index (PASI) ≤1 or body surface area ≤3; patient pain numerical rating scale (NRS) score of ≤ 2; patient global disease activity numerical rating scale (NRS) score of ≤2; Health Assessment Questionnaire (HAQ) score ≤0.5; and tender entheseal points ≤1. Baseline demographic and clinical characteristics at the first visit and before commencing anti-TNF therapy were collected including sex, age at diagnosis of psoriasis and PsA, disease manifestation (peripheral joint  involvement, axial disease,  the presence of enthesitis, dactylitis and tenosynovitis), previous disease-modifying anti-rheumatic drug use, the number of active and damaged joint counts, patient global assessment, C-reactive protein (CRP), ESR as well as the health assessment questionnaire (HAQ) and SF 36 PCS. Descriptive analyses were conducted.

Results: Of the 307 patients treated with anti-TNF agents in our cohort, 17 patients were identified who were able to reduce the dose of anti-TNF agents with a total of 22 observation periods and continued to be in MDA for a mean duration of 23.7 ± 18.6 months. 15 patients were on etanercept and 2 on adalimumab. Most patients were not treated concurrently with DMARDs at the time they reduced/stopped the dose of anti-TNF agent. 8 patients reduced their dose and did not flare for a mean duration of 38.7 ± 16.3 months, while 9 patients flared after a mean duration of 13.2 ± 11.2 months. Patients stopped the medications for the following reasons: 11 patients were in remission, 3 patients due to infection, 2 cases due to patient preference and one case due to non improvement in skin disease.

Conclusion: In this study, we identified a group of patients who have stopped or reduced the dose of anti-TNF medications after being in remission. Eight patients have reduced the dose with no evidence of disease exacerbation. The data support the need for randomized controlled trials to better define the duration of anti-TNF therapy in psoriatic arthritis.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/anti-tnfa-discontinuation-in-psoriatic-arthritis-is-it-possible-after-achieving-minimal-disease-activity/