Brief ReportMinimum Effective Dosages of Anti-TNF in Rheumatoid Arthritis: A Cross-sectional StudyDosis efectiva mínimas de anti-TNF en artritis reumatoide: un estudio transversal
Introduction
Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disease with a fluctuant but progressive course, leading, without treatment, to cartilage damage, bone erosions, and joint destruction, the main causes of long-term disability.1
Although the registered doses of anti-TNFs are at the top of the group dose response curve and under-treatment is not expected to be very frequent, the use of standard dosages in clinical practice may result in under or over treatment2 once remission or low disease activity have been achieved, making it reasonable to attempt treating patients on an individualized schedule.
Clinical experience confirms the long-term efficacy of standard dosages for anti-TNF drugs, evaluation is still necessary to determine if reduced dosages could maintain clinically controlled patients. There are some reports addressing the issue of stopping, lowering, or increasing the dosages inpatients in remission,3, 4 showing that up to 50% of patients relapse if the drug is stopped, and reintroduction of the therapy might not achieve previous results. However, tapering anti-TNF dosages seems to preserve the clinical efficacy in most patients.5 Consequently, RA patients treated with anti-TNF who are in maintained remission6 could benefit from treatment adjustment in order to find the lowest effective dose.
The aim of the study was to assess the anti-TNF dosages in RA patients, evaluating whether modified patterns could control patients clinically under our daily clinical practice.
Section snippets
Study Design and Patient Population
A cross-sectional, non-interventional study was conducted in the Hospital General Universitario Gregorio Marañón (HGUGM) in Madrid (Spain), from October 2010 to October 2011. During the study period, patients receiving anti-TNF for a minimum period of 12 months, and attending per routine follow-up the Biological Therapy Unit at the Rheumatology Department, were subsequently included. Requirements included being diagnosed with RA, according to the American College of Rheumatology's (ACR) 1987
Demographic and Clinical Data (Table 1)
195 RA patients were included. Participants were predominantly women (79%) and the global mean age was 58.1 (±14.9) years. Patients were distributed into 3 groups, according to the anti-TNF drug used: 81 patients in the ETN group (41.5%), 56 in the ADA group (28.7%), and 58 in the IFX group (29.7%). Mean disease duration (years) was statistically different between groups (P=.01) although most patients (42.2%) had a mean disease duration between 10 and 20 years. In the 2–5 year range of
Discussion
Although clinical experience confirms the long-term efficacy of standard dosages for anti-TNF drugs, this study, based on our daily clinical experience, provides real-life data on the use of different dosage regimens. While the mean DAS28 value was similar between groups, we found more responders by DAS28 among patients in ETN and ADA groups when compared to IFX group, despite the higher percentage of patients with dose escalation in the latter group. IFX dose escalation in clinical practice
Conclusions
Regarding our results, it seems reasonable, when clinical response has been achieved, to try to reduce the standard dosage in order to establish the minimum effective dose, because tapered doses do not seem to lead to high disease activity in some patients.
Conflict of Interest
The authors declare no conflict of interest.
Protection of Human and Animal Subjects
The authors declare that the procedures followed were in accordance with the regulations of the responsible Clinical Research Ethics Committee and in accordance with those of the World Medical Association and the Helsinki Declaration.
Confidentiality of Data
The authors declare that they have followed the protocols of their work centre on the publication of patient data and that all the patients included in the study have received sufficient information and have given their informed consent in writing to participate in
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