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

Elise van Mulligen (Corresponding author), Pascal Hendrik Pieter de Jong, Tjallingius Martijn Kuijper, Myrthe van der Ven, Cathelijne Appels, Casper Bijkerk, Joop B. Harbers, Yael de Man, T.H. Esmeralda Molenaar, Ilja Tchetverikov, Yvonne P.M. Goekoop-Ruiterman, Jende van Zeben, Johanna M.W. Hazes, Angelique E.A.M. Weel, Jolanda J. Luime

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Abstract

OBJECTIVES: The aim of this study is to evaluate the effectiveness of two tapering strategies after achieving controlled disease in patients with rheumatoid arthritis (RA), during 1 year of follow-up.

METHODS: In this multicentre single-blinded (research nurses) randomised controlled trial, patients with RA were included who achieved controlled disease, defined as a Disease Activity Score (DAS) ≤ 2.4 and a Swollen Joint Count (SJC) ≤ 1, treated with both a conventional synthetic disease-modifying antirheumatic drugs (csDMARD) and a TNF inhibitor. Eligible patients were randomised into gradual tapering csDMARDs or TNF inhibitors. Medication was tapered if the RA was still under control, by cutting the dosage into half, a quarter and thereafter it was stopped. Primary outcome was proportion of patients with a disease flare, defined as DAS > 2.4 and/or SJC > 1. Secondary outcomes were DAS, European Quality of Life-5 Dimensions (EQ5D) and functional ability (Health Assessment Questionnaire Disability Index [HAQ-DI]) after 1 year and over time.

RESULTS: A total of 189 patients were randomly assigned to tapering csDMARDs (n = 94) or tapering anti-TNF (n = 95). The cumulative flare rates in the csDMARD and anti-TNF tapering group were, respectively, 33 % (95% CI,24% to 43 %) and 43 % (95% CI, 33% to 53 % (p = 0.17). Mean DAS, HAQ-DI and EQ-5D did not differ between tapering groups after 1 year and over time.

CONCLUSION: Up to 9 months, flare rates of tapering csDMARDs or TNF inhibitors were similar. After 1 year, a non-significant difference was found of 10 % favouring csDMARD tapering. Tapering TNF inhibitors was, therefore, not superior to tapering csDMARDs. From a societal perspective, it would be sensible to taper the TNF inhibitor first, because of possible cost reductions and less long-term side effects.

TRIAL REGISTRATION NUMBER: NTR2754.

Original languageEnglish
Pages (from-to)746-753
Number of pages8
JournalAnnals of the Rheumatic Diseases
Volume78
Issue number6
DOIs
Publication statusPublished - 1 Jun 2019

Keywords

  • anti-TNF therapy
  • csdmards
  • drug withdrawal
  • rheumatoid arthritis
  • tapering

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