Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement
Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.
Can We Discontinue Anti-TNF Therapy in Patients with Ankylosing Spondylitis and Remission? A Systematic Literature Review.
Abad3, Miguel A., Ortiz2, Ana M., Loza1, Estibaliz, Martinez Lopez1, Juan A., Rosario1, Maria P., Carmona1, Loreto
The introduction of anti-TNF agents has changed the management of patients with Ankylosing spondylitis (AS). At present there is no doubt about the efficacy of anti-TNF agents: Infliximab (IFX), etanercept (ETN) and Adalimumab (ADA) in controlling symptoms of AS. However, it is unclear which should be the attitude once patients have achieved remission.
To analyze the effect of discontinuing anti-TNF therapy in AS patients who achieved complete remission, and to assess whether the readministration would be effective and safe in case of relapse.
We conducted a systematic literature search for studies published up tol January 2009 on the efficacy of IFX, ETN and ADA in AS in Medline, Embase and the Cochrane Central databases. Selection criteria were: a)Type of study: clinical trials with any quality level (according to Jadad scale), b)Participants: patients with AS; c)Intervention: IFX, ETN or ADA d) Outcome: clinical relapse (according to ASAS criteria), time to relapse, effectiveness and safety after readministration of anti-TNFs. Two reviewers screened the titles and abstracts of the retrieved articles for selection criteria independently and collected the data by using ad hoc standard forms. One of them also graded the quality of the selected studies using a modification of the Oxford Centre for Evidence-based Medicine Levels of Evidence in its May 2001 update. A hand search was completed by reviewing the references of the included studies.
We identified a total of 406 titles, of which 390 were excluded after reading the title and abstract. The final number of selected studies for a detailed review was 16. Finally 9 were excluded and 6 included (1 was a randomized controlled trial, 1 an open trial and the other 4 were follow-up studies) 2 evaluated ETN, 4 IFX. We did not found studies regarding ADA.
After the discontinuation of IFX in AS patients who achieved remission, almost 100% relapsed. The mean time to relapse was 17.5 weeks ± 7.9 weeks (range 745). Patients who were in partial remission and those with normal C-reactive protein levels at the time point of withdrawal had longer times to relapse. Retreatment with IFX was safe and the clinical improvement was similar to that before the treatment was stopped.
All of AS patients on ETN relapsed after treatment cessation. The median time to recurrence after discontinuation was 6.2 weeks ± 3 weeks, with relapse at 3 months 75% and 100% 9 months. Retreatment with ETN was efficacious and safe after readministration over 1 year in patients with active AS.
The discontinuation of IFX leads to a relapse in almost all of AS patients who achieved remission within weeks or few months (level of evidence 1b, grade of recommendation A). The reinfusion of IFX in AS patients is safe, and the clinical improvement is comparable to the observed before the discontinuation (level of evidence 4, grade of recommendation C).
The discontinuation of ETN leads to a relapse in almost all of AS patients who achieved remission within weeks or few months (level of evidence 1b, grade of recommendation A). The reintroduction of ETN achieved similar clinical response to that observed previously (evidence level 4, recommendation grade C).
To cite this abstract, please use the following information:
Abad, Miguel A., Ortiz, Ana M., Loza, Estibaliz, Martinez Lopez, Juan A., Rosario, Maria P., Carmona, Loreto; Can We Discontinue Anti-TNF Therapy in Patients with Ankylosing Spondylitis and Remission? A Systematic Literature Review. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :516