FRI0154 Are There Negative Effects on Disease Activity and Function Associated with Failed Anti-TNF Dose Reduction Strategies for RA Patients?
Authors: L. Serhal, C. Holroyd, J. Zarroug, R. Armstrong, B. Davidson, N. Harvey, E. Dennison, C. Cooper, C.J. Edwards
Journal: Annals of the Rheumatic Diseases (2016)

<h3>Background</h3> We have previously described a strategy for Tumour Necrosis Factor inhibitor (TNFi) dose reduction (TDR) for patients with rheumatoid arthritis (RA) that selects patients with "deep remission" using combined clinical and ultrasound (US)[1]. <h3>Objectives</h3> The aim of this study was to assess the consequences of this TDR strategy [1] on the HAQ, DAS28-CRP and Area Under the Curve of CRP (AUC<sub>CRP</sub>) after follow-up (mean 28 months). <h3>Methods</h3> A longitudinal observational study was performed. Patients with RA (ACR-EULAR 2010), on TNFi for &gt;1 year, not taking oral corticosteroids, DAS28 ≤2.6 for &gt;6 months and absent power Doppler synovitis on US underwent TDR by one third. Patients failing TDR (clinically/on US) were re-escalated to full dose. Patients were divided into 3 groups: Non-reducers (group A), sustained dose reducers (group B) and failed dose reducers (group C). We investigated the initial (TNFi start date) and the last HAQ, DAS28 and AUC<sub>CRP</sub>, as well as before and after TDR. <h3>Results</h3> 152 patients with RA receiving TNFi were included. Between Oct 2011 &amp; May 2015, 67 (44%) underwent TDR. 3 patients were lost to follow-up. Dose reducers have been followed-up for a mean 30.5 months after TDR. A total of 29 (45%) failed the TDR after a mean (SD) of 9.5 (7.9) months. By a mean (SD) of 22.4 (11.6) months following dose re-escalation, 27 (93%) continued to receive their TNFi, while 2 (7%) had switched to a different biologic. Baseline characteristics of all groups were similar. However, we found that the initial HAQ score on starting TNFi was significantly higher for group A compared to groups B and C (mean 1.59 versus 0.95 and 1.28, respectively, p&lt;0.05) and was higher for group C compared to group B (p=0.05). When compared before and after reduction, both groups B and C showed a similar pattern of functional capacity and AUC<sub>CRP</sub>. Nevertheless, group B had lower last DAS28 (p&lt;0.05). While analysing the most recent DAS28 of group C following dose re-escalation, 32% had achieved DAS28 remission, 20% developed lower (LDA), 44% moderate (MDA) and 4% severe disease activity (SDA). Finally, we assessed the changes over time of DAS28 and HAQ scores. Group B had a higher DAS28 reduction then groups A and C (mean 3.6 vs. 2.43 and 2.75, respectively) (p&lt;0.05), who both had similar changes. Nonetheless, HAQ score changed similarly between all patients. <h3>Conclusions</h3> RA patients who fail dose reduction appear to have a higher DAS28 than those who were successful despite reintroduction of a standard dose of TNFi. However, in the majority of cases the level of DAS28 was &lt;3.2 (LDA or better). Failed dose reduction did not appear to cause loss of functional capacity (HAQ) or a greater cumulative exposure to inflammation (AUC<sub>CRP</sub>) compared to successful reduction. The functional capacity (HAQ) at TNFi initiation appears to predict the likelihood of successful dose reduction. <h3>References</h3> Marks JL et al. Does combined clinical and ultrasound assessment allow selection of individuals with rheumatoid arthritis for sustained reduction of anti-tumor necrosis factor therapy? Arthritis Care Res. 2015 May;67(6):746–53. <h3>Disclosure of Interest</h3> L. Serhal: None declared, C. Holroyd: None declared, J. Zarroug: None declared, R. Armstrong: None declared, B. Davidson: None declared, N. Harvey: None declared, E. Dennison: None declared, C. Cooper: None declared, C. Edwards Grant/research support from: Abbvie, MSD, Samsung, Novartis, Lilly, Sandoz, Celltrion, Celgene, Pfizer, BMS, Roche, Consultant for: Consultant, Speakers bureau: Speaker events