When Withdrawing Etanercept, Patients With Sustained Deep RA Remission Fare Best

Some data suggest that if biologics are withdrawn in patients with rheumatoid arthritis (RA) who have achieved remission, patients may be able to maintain their remission. However, other data suggest that patients are likely to experience disease flares if their therapy is withdrawn. One recent paper analyzed data from 3 studies on down-titration of etanercept in patients with RA and concluded that patients who have achieved disease control according to a stringent definition have a greater likelihood of remaining in remission after reducing their dose or withdrawing etanercept.

The study analyzed data from 3 randomized, controlled clinical trials: PRESERVE, PRIZE, and Treat-to-Target (T2T), all of which included induction with 50 mg of etanercept weekly, followed by double-blind maintenance, reduction, or withdrawal.

In the PRESERVE study in 834 patients, the proportions of patients with sustained deep remission, deep remission, sustained remission, remission, and low disease activity (LDA) according to a disease activity score in a count of 28 joints (DAS28) who maintained their remission after reducing their dose of etanercept were 81%, 67%, 58%, 56%, and 36%, respectively (P&thinsp;<.001). This trend in PRESERVE was significant when etanercept was discontinued and when other remission criteria—the American College of Rheumatology and European League Against Rheumatism Boolean remission criteria and the clinical disease activity index (CDAI) remission criteria—were used.

In the DAS28 analysis of the PRIZE study of 306 patients, patients who reduced their etanercept dose had a better response than the patients who discontinued etanercept or etanercept and methotrexate. In the CDAI analysis of PRIZE, 85% of those who reduced their dose maintained sustained remission, as did 50% and 47% of those who had remission and LDA, respectively (P <.01). Among those who discontinued etanercept and methotrexate, 52% maintained sustained remission, versus 0% of patients who had remission and 15% of those who had LDA.

In the T2T study of 491 patients, among those who discontinued etanercept, DAS28 remission was maintained by 100% patients with sustained deep remission and by 40%, 25%, 20%, and 4% of patients with deep remission, sustained remission, remission, and LDA, respectively (P&thinsp;<.001).

In the Boolean analysis of T2T, the proportions of patients who discontinued etanercept and maintained remission were 57%, 31%, and 3% of the patients with sustained remission, remission, and nonremission (P&thinsp;<.001). In the CDAI analysis, the proportions of patients who discontinued etanercept and maintained remission were 33%, 39%, 9%, and 0% of the patients with sustained remission, remission, LDA, and moderate disease activity. (P&thinsp;<.001).

According to the authors, this analysis demonstrates that, overall, the likelihood of maintaining remission or LDA after reducing or discontinuing etanercept follows a trend in which those who have sustained deep remission are the most likely to maintain a response.

Reference

Tanaka Y, Smolen JS, Jones H, Szumski A, Marshall L, Emery P. The effect of deep or sustained remission on maintenance of remission after dose reduction or withdrawal of etanercept in patients with rheumatoid arthritis. Arthritis Res Ther. 2019;21(1):164. doi: 10.1186/s13075-019-1937-4.