Order of TNF inhibitor, csDMARD tapering does not impact outcomes for RA patients
medwireNews: Findings from the TARA trial suggest that rheumatoid arthritis (RA) patients undergoing treatment tapering experience similar flare rates over 2 years irrespective of whether tumor necrosis factor (TNF) inhibitors or conventional synthetic (cs)DMARDs are tapered first.
“Because of similar effects from a clinical viewpoint, financial arguments may influence the decision to taper TNF-inhibitors first,” say Elise van Mulligen (Erasmus MC, Rotterdam, the Netherlands) and fellow researchers.
The multicenter, single-blind study included 189 adult RA patients with well-controlled disease (DAS ≤2.4 and swollen joint count [SJC] ≤1 at two assessments in a 3-month period) on treatment with a TNF inhibitor and a csDMARD who were randomly assigned to taper their TNF inhibitor over 1 year and their csDMARD in the following year, or vice versa. TNF inhibitors were tapered by doubling the dosing interval followed by halving the dose and then stopping, while csDMARDs were tapered through gradual dose reduction followed by discontinuation.
At the 2-year follow-up, the risk for disease flare (DAS >2.4 and/or SJC >1) was comparable among patients who tapered their TNF inhibitor first and those who tapered their csDMARD first, with corresponding rates of 62% and 61%. Flares happened after a median of 12.0 and 9.5 months, respectively.
Rates of disease-free remission (DFR) were also not significantly different in the two groups, at 11% and 20%, respectively, and there were no significant differences in disease activity and functional ability scores at the 2-year follow-up. Rates of adverse events were comparable in the two arms.
van Mulligen and team note in the Annals of the Rheumatic Diseases that flare rates in the trial “were high,” but were “within the range of previous reported flare rates (51%–77%),” suggesting that the findings “are generalisable to clinical practice.”
They add: “Ideally, rheumatologists want to be more certain about which patient is able to taper successfully, as current tapering strategies are based on a trial-and-error approach, which results in high flare rates that significantly influence patients’ lives.”
And the team concludes that “future studies should focus on patient subsets eligible to […] taper medication to reduce the amount of flares and to increase the number of patients that reach DFR.”
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