Tapering TNF blockers in axSpA and psoriatic arthritis: a successful approach

In both psoriatic arthritis (PsA) and axial spondylarthritis (axSpA), a treat-to-target (T2T) TNF blocker tapering strategy showed to be non-inferior to a T2T strategy without tapering regarding the proportion of patients still in low disease activity at 12 months. The only disadvantage of this approach was an increase in the use of other medications, especially non-steroidal anti-inflammatory drugs (NSAIDs) in the tapering group.

Although TNF blockers are safe and effective, high costs and a somewhat increased infection risk are long-term drawbacks. Therefore, tapering in patients that successfully achieved low disease activity or remission in PsA or axSpA might be a valuable approach. Dr Celia Michielsens (Sint Maartenskliniek and Radboud Institute for Health Sciences,  the Netherlands) and her team investigated whether a T2T strategy with tapering is non-inferior (with a pre-specified non-inferiority margin of 20%) compared with a T2T strategy without tapering in a randomised, controlled, open-label, non-inferiority trial [1]. All participants used TNF inhibitors and had stable low disease activity for ≥6 months. They were randomised (2:1) to a T2T tapering or no-tapering strategy and followed for 12 months. Low disease activity was defined as a Psoriatic Arthritis Disease Activity Score (PASDAS) ≤3.2 for PsA, and/or Ankylosing Spondylitis Disease Activity Score (ASDAS) <2.1, and/or judgement of physician and patient.

Of the 81 participants in the tapering group, 52% had PsA and the rest had axSpA. At 12 months, 73% of participants in the non-tapering group and 69% in the tapering group achieved low disease activity. This difference was well below the inferiority margin, thus confirming non-inferiority. At 12 months, 58 (72%) participants of the tapering group were successfully tapered. Patients in the tapering group used more other medications, a difference that was statistically significant regarding NSAID use (54% vs 24%; P=0.002). However, the risk of grade 3/4 infections was 46% lower and the risk of injection site reactions was 23% lower in the tapering compared with the non-tapering group.

Taken together, there was no significant difference between a tapering and a non-tapering approach regarding disease activity. “This might have been because we used not a fixed but an individualised tapering approach,” Dr Michielsen said. Moreover, tapering led to a substantial reduction in TNF inhibitor use.

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   1. Michielsens C, et al. Treat-to-target dose reduction and withdrawal strategy of TNF inhibitors in psoriatic arthritis and axial spondyloarthritis: a randomized controlled non-inferiority trial. OP0261, EULAR 2022, 1–4 June, Copenhagen, Denmark.

 

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Posted on 7 June, 2022