Team: ARCTIC REWIND, aka the “TNF Inhibiting Tritons”

Base Article: Lillegraven S, Paulshus Sundlisæter N, Aga AB, et al. Effect of tapered versus stable treatment with tumour necrosis factor inhibitors on disease flares in patients with rheumatoid arthritis in remission: a randomised, open label, non-inferiority trial. Ann Rheum Dis. 2023;82(11):1394-1403. doi:10.1136/ard-2023-224476

Authors: University of California San Diego Fellowship Program

1. Rashmi Dhital, MBBS, third year rheumatology fellow, UCSD
2. Neha Chiruvolu Singh, DO, second year rheumatology fellow, UCSD
3. Brian Pedersen, MBBS, rheumatology attending, UCSD

Team Overview

In the rheumatoid arthritis (RA) realm, where the game is all about controlling inflammation, TNF inhibitor (TNFi) therapy takes center court. This trial addressed the knowledge gap on TNFi tapering and withdrawal in RA patients with prolonged clinical remission – a period when patients anticipate medication reduction, and clinicians may consider tapering.

This pragmatic Norwegian study from 2013 to 2019 included RA patients in remission for over one year on stable TNFi therapy (+/- conventional disease-modifying antirheumatic drugs). Players were randomized to either continue their TNFi full court press at the current dose or begin to taper (halving TNFi for 4 months and withdrawing if still in remission). TNFi was restarted at full dose if a flare occurred.

The scoreboard tells an intriguing tale: the 12-month mark revealed a significant disparity in flare rates, 27/43 (63%) in the tapering group versus 2/41 (5%) in the stable TNFi group. During the initial 4 months of half-dose TNFi, 12% flared in the tapering group in contrast to none in the stable group. The tapering group was more likely to receive steroids. Upon reinstating treatment, however, both groups achieved comparable remission (tapering vs stable groups: Boolean [67% vs 63%] and DAS [88% vs 85%]).

This study provides valuable play-by-play insight for shared decision-making by addressing both flare risk and the possibility of regaining disease control. It also highlights the unmet need to identify predictors of who will flare and who will not upon medication tapering, and those for whom remission will not be recaptured.

Want to learn more?

See the Q&A on theMednet.org about the following question: Do you advocate to taper the TNFi or simply continue to monitor for long term adverse events? 

Next report: EMBRACE

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