Infliximab withdrawal not recommended for AS patients in remission
medwireNews: The decision to discontinue infliximab in ankylosing spondylitis (AS) patients who have achieved sustained remission “should be taken with considerable caution,” say Spanish researchers who found that over half relapsed after the tumor necrosis factor (TNF) inhibitor was withdrawn.
They explain that “a recent consensus paper from the Spanish Society of Rheumatology and the Spanish Society of Hospital Pharmacy stressed the possibility of withdrawing anti-TNF treatment in some patients who maintain good clinical response after intensive reduction of anti-TNF treatment, but the evidence supporting this recommendation is lacking.”
The team therefore identified 107 individuals who received infliximab 5 mg/kg as the first anti-TNF therapy for active AS at 23 hospitals in Catalonia, Spain. Of these, 36 were considered to be in persistent remission as they had a BASDAI score of 2 points or less, normal C-reactive protein (CRP) levels, and absence of active arthritis, enthesitis, and/or extra-articular manifestations for at least 6 months without use of steroids or nonsteroidal anti-inflammatory drugs.
Once infliximab was discontinued for the patients in sustained remission, 33.3% remained in remission, 58.3% experienced a relapse, and 8.3% were lost to follow-up over the 12-month study course. Half of the patients that relapsed did so within 6 months of treatment discontinuation.
Reintroduction of infliximab among the 21 individuals who relapsed led to 52% once again achieving remission, but 48% did not. Seven of these patients without remission had a good clinical response to infliximab, defined as the absence of flare, a BASDAI score of less than 4 points, and/or CRP levels below 0.8 mg/dL. But for the remaining three individuals, the treatment was considered ineffective and they had to switch to a different TNF inhibitor.
Jordi Gratacós, from Universitat Autònoma de Barcelona, and fellow REMINEA investigators summarize: “[A]lthough the reintroduction of infliximab treatment was safe, half of the patients did not achieve the same clinical response as prior to treatment withdrawal.”
They were unable to identify any demographic, clinical, or biologic factors that differed significantly between patients who did and did not relapse after infliximab withdrawal.
In light of these results, Gratacós et al say that “it seems unreasonable to propose withdrawal as an objective of the treatment strategy, at least at present, in the absence of any objective predictive factors of persistent clinical remission after treatment withdrawal.”
The REMINEA study results are published in Arthritis Research & Therapy.
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