Background/Purpose:

The increased use of tumor necrosis factor inhibitors (TNFi) has improved clinical outcomes for psoriatic arthritis (PsA) patients and made low disease activity (LDA) and remission viable treatment goals.  Due to factors such as pharmacoeconomic considerations, concern for long term side effects, and patient preferences, there has been increasing interest in the possibility that TNFi may be discontinued by patients achieving remission or LDA, with maintenance of clinical benefit. The purpose of this study is to determine the duration of clinical benefit among PsA patients discontinuing TNFi while in LDA, and to identify patient characteristics and disease related factors that may be associated with prolonged clinical benefit.

Methods:

An observational cohort study of PsA patients in the CORRONA registry who discontinued TNFi use after achieving LDA. LDA was defined as CDAI ≤ 10 and skin psoriasis physician global assessment ≤ 20/100.  Patients were considered to have lost clinical benefit if: 1) increase in CDAI to > 10; 2) increase in skin assessment to >20; or 3) increase in concomitant DMARD or prednisone doses or start of DMARD, prednisone, or biologic agents. Clinical data were collected at baseline (the time of TNFi discontinuation) and at loss of clinical benefit or the last clinic visit.  Kaplan Meier analyses were used to estimate duration of clinical benefit. Both univariable and multivariable Cox proportional hazard analyses were used to evaluate characteristics associated with duration of benefit. 

Results:

Of 5945 PsA patients in CORRONA, 325 discontinued TNFi while in LDA and had follow up data available. Mean age was 52.6 years, mean BMI 30.1, mean duration of PsA 9.8 years, and 51.9% were female. 52.6% of patients discontinued their 1^st TNFi, and 31.1% discontinued their 2^ndTNFi. Mean duration of TNFi use was 1.5 years. 53.5% used TNFi as monotherapy, 42.2% used concomitant MTX; 29% took low dose prednisone. 146 patients lost clinical benefit, due to: increased CDAI (31.5%), initiation or increase in DMARD (32.2%), TNFi restart (6.8%), initiation or increase in prednisone (9.6%) or worsening skin disease (15.8%).  The median time to loss of benefit was 29.2 months.  179 patients still had persistent benefit at their last clinic visit.  Patients with higher disease activity at TNFi discontinuation had increased risk of losing clinical benefit ( hazard ratios [HR] for:  CDAI > 3.2 vs <3.2 - HR 1.43 (p = 0.032), patient global assessment > 5 vs < 5/10 - HR 1.7 (p= 0.007), moderate vs low DAS - HR 1.65 (p = 0.017). Interestingly smokers had significantly higher risk for loss of benefit (HR vs non-smokers 1.76; p= 0.027) in both univariable and multivariable analysis. Number of TNFi used and overweight or obese status did not significantly affect loss of benefit.

Conclusion:

PsA patients who achieve LDA on treatment may maintain clinical benefit after discontinuation of TNFi. Patients with higher disease activity at the time of discontinuation and smokers may have less success at stopping therapy.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/persistence-of-low-disease-activity-after-tumor-necrosis-factor-inhibitor-withdrawal-in-patients-with-psoriatic-arthritis/