Conflict of interest : NONE.

Background/Purpose

Attaining remission or at least low-disease activity (LDA) is a goal achieved in a significant proportion of rheumatoid arthritis (RA) patients thanks to the development of TNF blockers. In these patients, reduction or withdrawal of anti-TNF represent the main adjustment strategies in view to decrease the use of TNF blockers for safety and economic concerns.

Our aim was to 1) compare the maintenance of remission or LDA after anti-TNF withdrawal in comparison to anti-TNF continuation 2) compare the maintenance of remission or LDA after anti-TNF dose reduction in comparison to anti-TNF continuation.

Methods

A systematic literature review searching for controlled trials comparing anti-TNF withdrawal or anti-TNF dose reduction and anti-TNF continuation in RA patients achieving LDA or remission was conducted using the Embase, PubMed, Cochrane library, and ACR/EULAR meeting databases, updated until June 2014. The two primary endpoints were 1) maintenance of remission or LDA after anti-TNF withdrawal 2) maintenance of remission or LDA after anti-TNF dose reduction. Meta-analysis was performed using the inverse variance approach and statistical heterogeneity was assessed with the Cochran Q-test and I² values.

Results

After systematic literature review, 6 controlled trials comparing anti-TNF withdrawal (725 RA patients in 4 trials) or anti-TNF dose reduction (694 RA patients in 4 trials) and anti-TNF continuation in RA patients achieving LDA or remission were selected for meta-analysis. For the comparison of anti-TNF withdrawal versus anti-TNF continuation, meta-analysis indicates ORs (95% CI) of 4.29 (3.04-6.07) for maintenance of remission (p<0.00001) and 5.33 (3.65-7.79) for maintenance of LDA (p<0.00001) (Figure 1), in favour of anti-TNF continuation. For the comparison of anti-TNF dose reduction versus anti-TNF continuation, meta-analysis indicates ORs (95% CI) of 1.60 (1.15-2.24) for maintenance of remission (p=0.006) and 1.31 (0.88-1.95) for maintenance of LDA (not significant) (Figure 2), in favour of anti-TNF continuation.

Conclusion

Anti-TNF dose reduction appears as a possible strategy for maintenance of LDA or even remission, while anti-TNF withdrawal appears as a risky strategy in RA patients who achieved LDA or remission.

Fig 1 – Meta-analysis of controlled trials assessing the maintenance of LDA after anti-TNF withdrawal in comparison to anti-TNF continuation in RA.

Fig 2 – Meta-analysis of controlled trials assessing the maintenance of LDA after anti-TNF dose reduction in comparison to anti-TNF continuation in RA.