OA02 Real-world experience of dose tapering TNF inhibitors in rheumatoid arthritis: Long-term results
Authors: Lwin May Nwe , Nooh Noor , Holroyd Christopher R , Lin Sharon X , Culliford David , Fraser Simon D , Edwards Christopher J 
Published: April 2023

Abstract

Background/Aims
If sustained disease control is achieved in RA then tapering is supported by recommendations. However, this may cause loss of disease control with subsequent damage. A problem in assessing tapering is the short-term nature of studies. We wanted to explore the long-term use of tapering strategies.

Methods
Our biologics database has collected information since 2005. Our approach, refined with PPI, for people receiving TNF inhibitors (TNFi) has been to dose taper by one-third and then 50% if remission was achieved (DAS28&lt;2.6 on 2 occasions &gt;6 months apart, no corticosteroids). We initially required absence of power doppler (PD) in the hands (stopped in 2017). Failure of tapering was defined as a flare (DAS28&gt;2.6, PD synovitis or patient-reported) resulting in a return to full dose, stopping the TNFi, or changing to another advanced therapy (bDMARD, tsDMARD). We explored associations between time on dose-reduction therapies and individual characteristics.

Results
1180 patients started biological therapies during 2005-2021 with 668 receiving a TNFi. 119 (18%) were dose-tapered by one-third and of these 40 (30%) then by one-half. Over median follow-up of 2.2 years (IQR 0.7,5.9) with maximum follow-up of 8.93 years, tapering failed in 88 (74%). Of those failing, 50% achieved DAS28 remission, 18% low disease activity (LDA), 32% moderate (MDA) and none high (HDA) within 12 months. A Kaplan-Meier plot showed one-third of individuals failed tapering within the first year with two-thirds by 3 years. Logistic regression showed (Table 1) no significant effect of age, sex, time between diagnosis and TNFi, seropositivity, smoking, or DAS28 score. However, there was an association between concomitant use of methotrexate and reduced failure of tapering (HR 0.60 (CI 0.39,0.94) p = 0.03).

Conclusion
In a real-world setting, tapering is well accepted and occurred in around 20% of individuals. Two-thirds maintain tapering after 1 year with around one-third by 3 years. Predictors of success are limited although concurrent methotrexate use appears associated with continued tapering. However, around a third of patients who fail tapering do not return to remission/LDA when the full dose of TNFi is restarted.
Disclosure
M. Lwin: None. N. Nooh: None. C.R. Holroyd: Member of speakers’ bureau; Abbvie, BMS, Celltrion, Chugai, Galapagos/Gilead, Janssen, Lilly, Napp, Novartis, Pfizer, Roche and UCB. Other; Sponsorship / advisory board: Abbvie, BMS, Celltrion, Chugai, Galapagos/Gilead, Janssen, Lilly, Napp, Novartis, Pfizer, Roche and UCB. S.X. Lin1: None. D. Culliford: None. S.D. Fraser: None. C.J. Edwards: Member of speakers’ bureau; Abbvie, Astra Zeneca, BMS Celltrion Chugai, Gilead, Galapagos, GSK, Janssen, Eli Lilly, Pfizer, Roche, Sandoz, Samsung. Grants/research support; Abbvie, Astra Zeneca, BMS Celltrion Chugai, Gilead, Galapagos, GSK, Janssen, Eli Lilly, Pfizer, Roche, Sandoz, Samsung. Other; Advisory boards: Abbvie, Astra Zeneca, BMS Celltrion Chugai, Gilead, Galapagos, GSK, Janssen, Eli Lilly, Pfizer, Roche, Sandoz, Samsung.