Abstract
BackgroundRecent data suggest that anti-TNF doses can be reduced in ankylosing spondylitis (AS) patients. Some authors even propose withdrawing treatment in patients in clinical remission; however, at present there is no evidence to support this.ObjectiveTo assess how long AS patients with persistent clinical remission remained free of flares after anti-TNF withdrawal and to evaluate the effects of treatment reintroduction. We also analyze the characteristics of patients who did not present clinical relapse.MethodsMulticenter, prospective, observational study of a cohort of patients with active AS who had received infliximab as a first anti-TNF treatment and who presented persistent remission (more than 6 months). We recorded at baseline and every 6–8 weeks over the 12-month period the age, gender, disease duration, peripheral arthritis or enthesitis, HLA-B27 status, BASDAI, CRP, ESR, BASFI, and three visual analogue scales, spine global pain, spinal night time pain, and patient’s global assessment.ResultsThirty-six out of 107 patients (34%) presented persistent remission and were included in our study. After treatment withdrawal, 21 of these 36 patients (58%) presented clinical relapse during follow-up. Infliximab therapy was reintroduced and only 52% achieved clinical remission, as they had before the discontinuation of infliximab; in an additional 10%, reintroduction of infliximab was ineffective, obliging us to change the anti-TNF therapy. No clinical or biological factors were associated with the occurrence of relapse during the follow-up.ConclusionsTwo thirds of patients in clinical remission presented clinical relapse shortly after infliximab withdrawal. Although the reintroduction of infliximab treatment was safe, half of the patients did not present the same clinical response that they had achieved prior to treatment withdrawal.
Highlights
Recent data suggest that anti-TNF doses can be reduced in ankylosing spondylitis (AS) patients
Infliximab therapy was reintroduced and only 52% achieved clinical remission, as they had before the discontinuation of infliximab; in an additional 10%, reintroduction of infliximab was ineffective, obliging us to change the anti-TNF therapy
Patients were included in the cohort and started infliximab treatment if they were aged 18 or over, had a diagnosis of AS according NY criteria, presented a disease duration longer than 1 year, and fulfilled criteria for anti-TNF treatment according to the Guidelines of the Spanish Society of Rheumatology (SER) (BASDAI ≥ 4, despite treatment with 2 nonsteroidal anti-inflammatory drugs (NSAID) for a minimum of 3 months at full dose) [12]
Summary
Recent data suggest that anti-TNF doses can be reduced in ankylosing spondylitis (AS) patients. Data from uncontrolled studies and from clinical practice support the possibility of reducing anti-TNF doses below the normal levels licensed in AS patients with good clinical response, and especially in patients in clinical remission [5,6,7]. In this sense, a recent consensus paper from the Spanish Society of Rheumatology and the Spanish Society of Hospital Pharmacy [8] stressed the possibility of withdrawing anti-TNF treatment in some patients who maintain good clinical response after intensive reduction of anti-TNF treatment [8], but the evidence supporting this recommendation is lacking
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