'Little to no benefit' in TNF inhibitor dose reduction for axial spondyloarthritis
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Reducing TNF-inhibitor treatments for patients with axial spondyloarthritis may produce “little to no” clinical benefit, according to data published in Arthritis Care & Research.
“Dose reduction of TNFi has been applied through various approaches including step down, extending regular intervals of drug administration, and full withdrawal, however there is currently no standardized strategy for this,” Daeria O. Lawson, HBSc, of McMaster University and Toronto Western Hospital, and colleagues wrote. “The understanding of the underlying axSpA disease activity such as inflammatory changes and radiographic progression when patients are tapered off of TNFi is limited, and these strategies require close monitoring for indicators of disease relapse.”
They added, “It still remains unclear in which patients it is appropriate to implement dose reduction strategies (if at all) and how to incorporate safety checkpoints for disease flare.”
To determine the effectiveness and safety of reducing TNF-inhibitor doses, compared with usual care, among patients with axial SpA, Lawson and colleagues conducted a meta-analysis of studies contained in the Central, Embase, Medline and trial registry databases. Focusing on randomized clinical trials that tested any of the five reference TNF inhibitors approved for axial SpA, the researchers included six studies totaling 747 participants. They excluded trials evaluating biosimilars.
The researchers pooled data using randomeffects models, with subgroup analyses performed for type of TNF inhibitor, history of exposure and follow-up duration. Outcomes included Assessment in Spondyloarthritis International Society (ASAS) response, remission criteria, disease activity and relapse and safety.
According to Lawson and colleagues, there were fewer ASAS40 (RR = 0.62; 95% CI, 0.49-0.78) and ASAS partial remission (RR = 0.17; 95% CI, 0.06-0.46) events with the reduced dose, compared with usual treatment. Additionally, there was a mean increase in the Bath Ankylosing Spondylitis Disease Activity Index score (mean difference = 0.35; 95% CI, 0.1-0.6), and no difference in Creactive protein levels (0.16; 95% CI, –0.76 to 1.07) with the reduced dose. The researchers also noted more disease flares or relapses (RR = 1.73; 95% CI, 1.32-2.27) with the reduced dose.
However, there were no differences in infection rates (IRR = 0.98; 95% CI, 0.76-1.25) or injection or infusion reactions (IRR = 0.71; 95% CI, 0.42-1.19), the researchers wrote.
“To our knowledge, this is the first systematic review with a meta-analysis of [randomized controlled trials] investigating the safety and efficacy of TNFi dose reduction for the treatment of axSpA,” Lawson and colleagues wrote. “Our findings confirm previous studies where standard TNFi doses suggest some benefit for disease activity and are more efficacious for achieving and maintaining stable disease.” – by Jason Laday
Disclosure: Lawson reports no relevant financial disclosures. Coauthor Robert D. Inman, MD, of Toronto Western Hospital and the University of Toronto, reports consulting fees from AbbVie, Amgen, Janssen, Lilly, Merck and Novartis.
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