Gradual TNFi vs csDMARD Tapering in Rheumatoid Arthritis

In patients with rheumatoid arthritis (RA), flare rates associated with the tapering of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or tumor necrosis factor inhibitors (TNFis) are similar up to 9 months, according to the results published in Annals of the Rheumatic Diseases. After 1 year, however, a nonsignificant difference of 10% that favored csDMARD tapering was reported.

The multicenter, single-blinded randomized TARA trial was conducted in 12 rheumatology centers in the Southwestern part of The Netherlands. The investigators sought to compare the effectiveness of 2 tapering strategies — gradually tapering csDMARDs or gradually tapering TNFis — in patients with RA who had controlled disease with a combination of csDMARDs and a TNFi. Controlled disease was defined as a Disease Activity Score (DAS) of ≤2.4 and a swollen joint count of ≤1 in patients receiving treatment with a csDMARD plus a TNFi. Eligible patients were randomly assigned into 1 of 2 groups: gradual tapering of csDMARDs or gradual tapering of TNFis. Patient medication was tapered if their disease was still under control by cutting the dosage into half, then into a quarter, and then discontinuing treatment with the agent.

The primary study outcome was the proportion of patients who experienced a disease flare, which was defined as a DAS >2.4 and/or a swollen joint count of >1. Secondary outcomes included DAS, European Quality of Life-5 Dimensions (EQ-5D), and functional ability (Health Assessment Questionnaire Disability Index [HAQ-DI]) after 1 year and over time.

A total of 189 individuals participated in the study, 94 of whom were randomly assigned to the tapering csDMARD arm and 95 of whom were randomly assigned to the tapering TNFi group. Cumulative flare rates were 33% (95% CI, 24%-43%) in the csDMARD tapering group and 43% (95% CI, 33% to 53%) in the anti-TNF tapering group (P =.17). The mean DAS, HAQ-DI, and EQ-5D values did not differ between the 2 tapering groups after 1 year and over time.

The investigators concluded that the tapering of TNFi was not superior to the tapering of csDMARDs in patients with RA. They recommend the tapering of TNFis first, however, because of potential cost reductions and fewer long-term side effects. This recommendation supports the current European League Against Rheumatism guidelines.

Reference

van Mulligen E, de Jong PHP, Kuijper TM, et al.  Gradual tapering TNF inhibitors versus conventional synthetic DMARDs after achieving controlled disease in patients with rheumatoid arthritis: first-year results of the randomised controlled TARA study [published online April 6, 2019 ]. Ann Rheum Dis. doi:10.1136/annrheumdis-2018-214970