Date: Sunday, October 21, 2018
Session Type: ACR Poster Session A
Session Time: 9:00AM-11:00AM
Background/Purpose: Patients with axial spondyloarthritis (axSpA) who have achieved a stable disease state and are undergoing treatment with tumour necrosis factor inhibitor (TNFi) therapy may opt for a dose reduction. Lowering the standard dosing regimen presents several potential risks including disease relapse. We investigated the efficacy of adjusting (reducing or withdrawing) the standard TNFi dose for the treatment of axSpA.
Methods: CENTRAL, Embase, and MEDLINE databases were searched (up to February 2018) along with trial registries and reference lists of relevant articles1,2. All randomized controlled trials (RCTs) evaluating a method of TNFi dose adjustment were assessed for eligibility. Data were pooled in RevMan 5.3 using a random-effects model for the following outcomes: Assessment of SpondyloArthritis international Society 40% (ASAS40) improvement criteria, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), C-reactive protein (CRP), remission, relapse and quality of life (QoL).
Results: 297 full-texts were reviewed for eligibility and 6 RCTs (737 participants) were included in the meta-analysis. There were higher ASAS40 rates with standard TNFi treatment as compared to an adjusted dose (risk ratio [RR] 0.63; 95% confidence interval [CI] 0.51 to 0.78; 3 studies; 538 participants; moderate quality evidence). There were no differences in the mean BASDAI (mean difference [MD] 0.40; 95% CI -0.11 to 0.91; 4 studies; 319 participants; moderate quality evidence) and mean CRP (MD 0.68; 95% CI -1.49 to 2.85; 4 studies; 319 participants; low quality evidence) between the standard and adjusted doses. There were higher rates of remission in the standard dose as compared to the adjusted dose (RR 0.65; 95% CI 0.56 to 0.77; 5 studies; 694 participants; low quality evidence). There were fewer events of disease relapse (i.e. BASDAI >4) in the standard versus adjusted dose (RR 1.20; 95% CI: 0.58 to 2.48; 2 studies; 156 participants; low quality evidence). QoL was not pooled due to clinical heterogeneity.
Conclusion: To our knowledge, this is the first review to incorporate a meta-analysis on TNFi dose adjustment in an axSpA population. Overall, this review found that axSpA patients who have achieved stable disease might experience little benefit or harm from TNFi withdrawal or reduction. The published data to date leave unclear the risk/benefit ratio of withdrawing treatment. Individualizing this decision is an important research question for future studies.
- Edwards, C., et al. (2017). Dosing down with biologic therapies: a systematic review and clinicians’ perspective. Rheumatol 56: 1847-1856.
- Navarro-Compan, V., et al. (2016). Anti-TNF discontinuation and tapering strategies in patients with axial spondyloarthritis: a systematic literature review. Rheumatol. 55: 1188-1194.
To cite this abstract in AMA style:Lawson DO, Eraso M, Mbuagbaw L, Aves T, Leenus A, Joanes M, Omar A, Inman RD. TNF Inhibitor Dose Tapering in Axial Spondyloarthritis: A Systematic Review and Meta-Analysis [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 10). https://acrabstracts.org/abstract/tnf-inhibitor-dose-tapering-in-axial-spondyloarthritis-a-systematic-review-and-meta-analysis/. Accessed September 25, 2021.
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