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Rheumatoid arthritis
Original article
What causes a small increase in radiographic progression in rheumatoid arthritis patients tapering TNF inhibitors?
  1. Chantal A M Bouman1,
  2. Alfons A den Broeder1,2,
  3. Aatke van der Maas1,
  4. Frank H J van den Hoogen1,2,
  5. Robert B M Landewé3 and
  6. Noortje van Herwaarden1
  1. 1Department of Rheumatology, Sint Maartenskliniek Nijmegen, The Netherlands
  2. 2Department of Rheumatology, Radboud University Medical Center, The Netherlands
  3. 3Department of Rheumatology, Academic Medical Center, Amsterdam, The Netherlands
  1. Correspondence to Chantal A M Bouman; c.bouman{at}maartenskliniek.nl

Abstract

Objective In a randomised controlled trial investigating tapering of TNF inhibitors (TNFi) compared with usual care (UC) in rheumatoid arthritis patients, minimal radiographic progression was more frequent in patients who attempted tapering. Possible explanations include higher incidence of flaring, higher mean disease activity or lower TNFi use.

Methods 18 months data from the DRESS study were used. Change in Sharp-van der Heijde (ΔSvdH) score (linear regression) and proportion of patients with >0.5 ΔSvdH (logistic regression) were used as outcomes. The cumulative incidence and number of short-lived and major flares per patient, mean time-weighted disease activity (MTW-DAS28-CRP) and TNFi use were used as independent variables. Regression models were performed stratified per study group and corrected for possible confounders.

Results 175 of 180 patients had 18-month data available. The mean ΔSvdH were 0.75 and 0.15 units with 37 of 116 (32%) and 9 of 59 (15%) patients exceeding 0.5 points in the tapering and UC group, respectively (both p<0.05). MTW-DAS28-CRP, but not incidence or number of short-lived or major flares, or TNFi use, was independently associated with the mean progression score, but only in the tapering group. Additional analyses on DAS28-CRP subcomponents showed that this was mainly caused by MTW swollen joint count. No confounders were identified.

Conclusions Radiographic progression was associated with higher MTW-DAS28-CRP (and especially swollen joint count), but only in patients who tapered TNFi. This finding stresses the importance of maintaining disease activity as low as possible in patients in whom TNFi is tapered and to check for radiographic progression regularly.

Trial registration number NTR 3216; Post-results.

  • Rheumatoid Arthritis
  • Treatment
  • DMARDs (biologic)
  • Disease Activity
  • Anti-TNF

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/rmdopen-2016-000327

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    Footnotes

    • Contributors CAMB, AAdB, AvdM, FHJvdH and NvH were involved in the study design. CB, AAdB, AvdM and NvH were involved in the data collection. CAMB, AAdB, AvdM, RBML and NvH performed the data analyses. All authors were involved in writing and revision of the manuscript.

    • Competing interests AAdB reports that he received a congress invitation from ABBVIE, BIOGEN, CELLTRION and ROCHE and received an expert witness fee from AMGEN and BI, all outside the submitted work. The other authors have no competing interests to report.

    • Patient consent Obtained.

    • Ethics approval Ethical approval was given by the local ethics committee (CMO region Arnhem-Nijmegen; NL37704.091.11).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The authors commit to making the relevant anonymised patient-level data available on reasonable request.