Background/Purpose:   While abrupt discontinuation strategies of anti-TNF drugs have been shown to result in frequent disease flares, tapering of dose may be a feasible option for  patients with inflammatory rheumatic disease in long-term remission. We aimed to assess the feasibility to taper anti-TNF drugs (either by dose reduction or by prolongation of dosing interval ) in patients with inflammatory rheumatic disease (RA, AS, adult-age JIA, PsA) in long-term remission

Methods: Patients with RA, AS, PsA or adult-age JIA in long-term remission of the disease (>6 months) were eligible for this prospective observational cohort study.  Baseline and 3-monthly follow-up visits data concerning medication and activity of the disease were recorded prospectively by a questionnaire. The desicions whether and how to taper (or increase in case of flare) anti-TNF therapy were left solely to the discretion of the treating physician, without any pre-specified protocol. Survival analyses, performed using a Cox proportional hazards model, were used to assess the predictors of failure of the tapering strategies (failure was defined as reinstitution of the usual/baseline dose of the anti-TNF drug).

Results: 132 patients (AS: 55, RA: 45, adult-age JIA: 22, PsA: 10) with at least one follow-up visit after tapering of anti-TNF therapy (corresponding to 176 patient-years of follow-up) have been analyzed.  Median time of follow-up per analyzed patient was 189 days (IQR 98-343 days). 70 (53%) patients were treated by etanercept, 37 (28%) by adalimumab, and 25 (19%) by infliximab. 50% fraction (or less) of the baseline dose  was reached in 81 (62%) patients. Within respective diagnoses, 50% fraction (or less) of the baseline dose was reached in 34 (62%) pts with AS, 17 (77%) with JIA, 5 (50%) with PsA, and 25 (56%) with RA. In 25 (19%) patients the subsequent flare of the disease activity required increase of the anti-TNF drug back to the baseline dose (i.e. the tapering strategy failed). Within the diagnoses, failures were observed in 7 (13%) of pts with AS, 1 (5%) with adult-age JIA, 3 (30%) with PsA, and 14 (31%) with RA. In univariate survival analyses, the risk of the tapering strategy failure was numerically higher in RA patients (HR 2.39, 95%CI 0.96-5.97) , PsA pts (HR 2.38, 95%CI 0.62-9.24), and lower in JIA pts (HR 0.32, 95%CI 0.04-2.60) as compared to AS patients (referent); the risk of failure was also numerically greater in pts treated with infliximab (HR 2.49, CI95% 0.95-6.58) as compared to etanercept (referent), or adalimumab (HR 1.41, CI95% 0.55-3.58).

Conclusion: This observational study from one academic center on patients with inflammatory rheumatic disease (RA, AS, PSA, adult-age JIA) in long-term remission showed, that after tapering of the anti-TNF drug dose (or prolongation of the dosing interval) 19% of pts required  reinstitution of the usual/baseline dose of the anti-TNF drug within the limits of the relatively short-term follow-up

ACR Meeting Abstracts - https://acrabstracts.org/abstract/evaluation-of-strategies-to-taper-anti-tnf-drugs-in-patients-with-inflammatory-rheumatic-disease-rheumatoid-arthritis-ankyloing-spondylitis-psoriatic-arthritis-adult-age-juvenile-idiopatic-arthrit/