OP0113 Gradual tapering tnf blockers versus conventional synthetic dmards in patients with rheumatoid arthritis in sustained remission: first year results of the randomised controlled tara-study
Authors: E. Van Mulligen, A. E. A. M. Weel, T.M. Kuijper, J.J. Luime, J.M.W. Hazes, P.H.P. de Jong
Journal: Annals of the Rheumatic Diseases (2018)

<h3>Background</h3> Clinical and radiographic outcomes in rheumatoid arthritis (RA) have improved enormously in the last two decades, due to early detection of the disease, early initiation of 'intensive' therapy and a treat-to-target approach. As a result, 50%–60% of early RA patients will achieve sustained remission during the first year of follow-up. In aforementioned cases current guidelines recommend to consider tapering treatment, but an optimal approach to gradually de-escalate conventional synthetic or biologic DMARDs (respectively csDMARDs and bDMARDs) is currently lacking. <h3>Objectives</h3> The aim of this study is to evaluate the effectiveness of two tapering strategies, namely gradual tapering of csDMARDs and anti-TNF therapy during one year of follow-up. <h3>Methods</h3> In this multicenter single-blinded randomised controlled trial RA patients in sustained remission for at least 3 consecutive months, defined as a DAS≤2.4 and a swollen joint count (SJC)≤1, which was achieved with csDMARDs and a TNF blocker were included. Eligible patients were randomised into gradual tapering csDMARDs followed by the TNF blocker or vice versa. Medication was tapered in three steps over the course of 6 months. Gradual tapering was done by cutting the dosage into half, a quarter and thereafter it was stopped. The primary outcome for the clinical effectiveness was disease flare defined as DAS44 &gt;2.4 and/or SJC&gt;1. Secondary outcomes were quality of life and functional ability. <h3>Results</h3> A total of 187 patients were randomly assigned to tapering csDMARDs (n=93) or tapering anti-TNF (n=94). Patients had an average symptom duration of 6.7 years and were predominantly female (66%) with an average age of 56.4 years (figure 1A). The cumulative flare ratio in the csDMARD and anti-TNF tapering group was respectively 32% and 41% (figure 1B), which corresponds with a hazard ratio of 0.91 (95% CI: 0.68 to 1.22, p=0.55). In the last 3 months the increase in cumulative flare ratio differs the most between the two groups. On the other hand, in 48% and 51% of patients respectively tapering csDMARDs or anti-TNF the medication could be completely withdrawn (figure 1C). Percentages of patients which are not completely tapered are higher than the flare ratios, due to loss of remission without a disease flare. Furthermore, mean DAS and mean HAQ over time, and after 1 year, did not differ between both tapering groups (figure 1D and E). <h3>Conclusions</h3> There were no significant differences in flare ratios, disease activity and functional ability between both tapering strategies during the first year of follow-up. Therefore, in RA patients who are in sustained remission we advise to taper anti TNF first, but before tapering therapy rheumatologists should take the risk of a disease flare and patient's wishes into account. <h3>Disclosure of Interest</h3> None declared