Treating RA With Infliximab, Adalimumab, or Golimumab May Allow for Later Biologic-Free Remission

Some patients with rheumatoid arthritis (RA) are able to sustain clinical remission after discontinuing their treatment with biologics, but little is known about which biologics present the best chance for patients to do so.

The Kansai Consortium for Well-being of Rheumatic Disease Patients (ANSWER) cohort, an observational, multicenter registry of patients in Japan, offered an opportunity to assess which biologics are most advantageous for achieving biologic-free remission in a real-world setting. A research team retrospectively analyzed data from the ANSWER cohort from 2011 to 2016, and recently reported findings in Arthritis Research and Therapy.

A total of 1307 patients were part of the cohort, and serial disease activity data were available for 572 of them. The biologics taken by these patients comprised 4 groups: anti—tumor necrosis factor (anti-TNF) monoclonal antibodies (infliximab, adalimumab, and golimumab), soluble TNF receptor or Fab fragments against TNF (etanercept and certolizumab pegol), the fusion protein CTLA4–Ig (abatacept), and an anti–interleukin-6 agent (tocilizumab). Patients could also receive conventional disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, and glucocorticoids.

Among patients who discontinued biologics, 181 were in remission (defined as a disease activity score in a count of 28 joints with C-reactive protein of under 2.3). Biologic-free remission maintenance rates for this group were 21.5% at year 1 and 12.2% at year 2. The median duration until biologic-free remission failure was 70 days (range, 58-93).

Read more about treat-to-target strategies in RA.

In analyzing the association between remission maintenance and the type of biologic drugs that patients had used, a notable difference emerged between patients who used infliximab, adalimumab, or golimumab (n = 95) versus those who received etanercept and certolizumab pegol (n = 32); in the former group, remission was maintained for a median of 98 days (range, 70-178), while in the latter group, remission was maintained for a median of 63 days (range, 35-105). Those taking abatacept (n = 17) had a median maintenance period of 73 days (range, 35-245), and those taking tocilizumab (n = 37) had a median remission of 42 days (range, 29-56).

Clinical factors associated with biologic-free remission included a shorter disease duration (under 2 years), and biologic-naïve status at the time of starting the later-withdrawn biologic. If remission was maintained continuously for more than 6 months before withdrawing the biologic, patients were more likely to maintain that remission afterward. Using methotrexate at the time of biologic discontinuation decreased the risk of remission failure, while using glucocorticoids raised the risk of disease flares.

While biologic-free remission is difficult to achieve, conclude the authors, using infliximab, adalimumab, or golimumab, followed by abatacept, may offer patients the best advantage.

Reference

Hashimoto M, Furu M, Yamamoto W, et al. Factors associated with the achievement of biological disease-modifying antirheumatic drug-free remission in rheumatoid arthritis: the ANSWER cohort study. Arthritis Res Ther. 2018;20(1):165. doi: 10.1186/s13075-018-1673-1.