Introduction
Rheumatoid arthritis (RA), a systemic inflammatory disease, could lead to significant joint destruction and functional disability due to improper treatment [
1]. It is critical to control disease activity to limit structural damage and functional impairment. In recent years, biological treatment has greatly advanced and revolutionized the therapy of RA [
5]. However, tapering strategy of biological agents has emerged as an important consideration after achieving remission, in light of the adverse event and economic burden [
6]. It brings to another challenging problem: once the treatment goal is reached, that is, remission or at least low disease activity (LDA), how should the therapy taper or even stop to avoid patient overtreatment.
Many studies have begun to explore that when patients reach LDA or remission, they can consider reducing or even stopping biological disease-modifying antirheumatic drugs (bDMARDs) [
9]. Based on the evidence from these studies, the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) include the choice of dose reduction in their latest guidelines, the core content of which is that “maintaining the treatment target does not necessarily mean maintaining the treatment intensity” [
12]. Therefore, the optimal reduction strategy of biological agents has become an important aspect for RA patients to achieve remission.
Some randomized controlled and observational studies for the withdrawal of tumor necrosis factor inhibitors (TNFi) in rheumatoid arthritis have been conducted [
15], suggesting that tapering is feasible. However, no cohort study has yet been reported to assess dose reduction or cumulative dose thresholds, and consequently, evidence on tapering strategies in the real world for RA remains lacking. Despite tapering strategies that have been proposed based on previous studies, patients in actual clinical practice often encounter poor treatment adherence and financial constraints which prevent them from following the established tapering schemes strictly. Therefore, it may be more pragmatic to identify a balance point during long-term follow-up, wherein maintaining a certain level of dose accumulation over a specific period of time could potentially result in favorable treatment outcomes. In order to implement tapering optimization, we conducted an observational study from a real-world cohort to identify the effective cut-off cumulative dose of etanercept in patients with methotrexate (MTX)-resistant RA, and give the points for correlation between tapering strategies and treat-to-target (T2T) principle [
20].
Discussion
According to the results of restricted cubic splines, we obtained the critical value of 2-year cumulative dose that can maintain the compliance of remission at 24 months was 1975 mg. Further combining with the cumulative cut-off dose at 6 and 12 months from the ROC curve, we obtained the recommended threshold dosing frequency of etanercept. It suggested that at least a certain cumulative dose of biological agents is necessary for the maintenance of long-term therapeutic effect in early treatment. And it is more conducive to the long-term control of the disease and improves the quality of life of patients.
Achievement of sustained remission or LDA is the overarching treatment goal in patients with RA to reduce the risk of joint damage and disability [
20]. Based on our results, the ENT saturated dosing therapy was significantly better than the non-saturated dosing therapy in respect of remission/LDA response, more importantly, sustained remission/LDA rate. Compared with the results of our previous study [
28], the proportion of patients achieving sustained remission and LDA at 24 months in the non-saturated group was 8.3% and 16.5% respectively, while 25.3% and 53.2% in the MTX + HCQ group. It partly suggested that the combination of csDMARDs was more benefit to the long-term prognosis of patients if the adequate dose or course of bioDMARDs treatment could not be guaranteed.
We also found that 52.8% of the patients benefited from the tapering regimen; that is, remission response could be maintained at 24 months, suggesting that a significant proportion still need adequate TNF therapy. In the STRASS study (Spacing of TNF-blocker injections in Rheumatoid ArthritiS Study), patients were randomized to either continuing full-dose TNF inhibitor (etanercept or adalimumab) or tapering it by spacing the injection interval. Thirty-nine percent of the patients stopped the TNF inhibitor in the tapering arm while maintaining the remission status [
18]. Smolen et al. investigated the effect of stopping etanercept; 43% of the patients remained in low disease activity over 1 year [
19]. Meanwhile, the proportion of patients achieving remission and LDA at 6 months among the saturated group was 38.9% and 50.0% respectively. From the result of previous report, the remission and LDA rate of combination of csDMARDs were 12.7% and 24.8% [
29]. Therefore, biological agents still showed advantages in early response to refractory RA patients. However, we still need further research to compare the efficacy of MTX plus HCQ or etanercept.
To our knowledge, rare study have been reported on the cost-effectiveness of a dose optimization strategy of TNFi therapy in RA patients. We found that the ICER yielded by the saturated dosing therapy was $5791.2 per QALY compared with the non-saturated dosing therapy, within the WTP threshold set as the per capita GDP of China. The medication costs were significantly reduced compared with the result of optimization and standardized control treatment ($17,085 vs $29,699) in the DRESS study, also reported that disease activity-guided dose optimization would be a more cost-effective approach than standardized control treatment.
In this study, we observed more patients received multidisciplinary care in the saturated dose group than in the non-saturated dose group. Although there are many options for the treatment of RA, due to its course migration, difficulty in remission, the patient’s compliance is poor, which leads to the risk of recurrence and damage to disease control. Effective and comprehensive disease management is the key to ensuring the treatment effect and achieving long-term remission. Thus, optimal disease management could enhance patient compliance, which is critical to controlling disease activity.
Our study has several limitations. First, the sample size of this study was small. It is difficult to find patients who use a single biological agent to finish the 2-year follow-up in the real world. Moreover, the assessment of the long-term impact of biological agents’ reduction is not comprehensive, such as the lack of adequate imaging evaluation evidence. Several studies have investigated the long-term feasibility and risks of TNF-blocker reduction or discontinuation in established RA, especially on radiographic progression [
10]. In this study, the current results are still prominent and meaningful and give instructive advice for trying to answer the specific maintenance scheme of biological agents for long-term treatment of RA.
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