Abstract

Background: In well-controlled rheumatoid arthritis (RA) tapering of DMARDs can be considered. According to the EULAR guidelines glucocorticoids should be tapered first, followed by biological (b)DMARDs or conventional synthetic (cs)DMARDs. In patients using both bDMARDs and csDMARDs, the order of tapering – bDMARD first versus csDMARD first – does not matter from a perspective of clinical outcomes and costs. Nevertheless, other factors might also be relevant for the choice of tapering order. The presence of anti-citrullinated protein antibodies (ACPA) is associated with a higher risk of flare. Therefore, we hypothesized that the efficacy of different tapering orders might be different for ACPA-positive than for ACPA-negative RA patients. Objectives: To determine whether there is a difference in risk of flare between a tapering TNFi-first versus a tapering csDMARD-first strategy in groups of ACPA-positive and ACPA-negative RA patients with well-controlled disease using both a TNFi and a csDMARD. Methods: Data from the TARA trial were used. The TARA trial was a multicentre, randomized-controlled trial in established RA patients with a well-controlled disease (DAS44≤2.4 and SJC≤1) for at least 6 months, which was achieved with both a csDMARD and TNFi. Patients were randomized to either gradually tapering their csDMARD (mostly methotrexate) in the first year, followed by gradually tapering their TNFi (mostly etanercept or adalimumab) in the second year, or vice versa. In ACPA-positive and ACPA-negative RA patients we compared flare free survival percentages over two years between both tapering strategies. A flare was defined as a DAS44>2.4 and/or SJC>1. Results: Of the 135 included ACPA-positive patients, 66 tapered their TNFi first and 69 tapered their csDMARD first. The cumulative flare free survival over 2 years was similar for the two tapering strategies in this group (33% and 35%, HR 1.2, 95% CI 0.8-1.8, Figure 1). Of the 53 ACPA-negative patients, 29 tapered their TNFi first and 24 tapered their csDMARD first. The cumulative flare free survival over 2 years was similar for the two tapering strategies (39% and 36%, HR 0.9, 95% CI 0.5-1.9, respectively, Figure 1). Conclusion: In ACPA-positive and in ACPA-negative RA, the efficacy of TNFi-first versus a csDMARD first tapering strategy is similar with regard to the risk of flare. This suggests that ACPA status might not aid in the choice of tapering strategy at initiation of DMARD tapering when patients use both a TNFi and a csDMARD. REFERENCES: NIL. Acknowledgements: NIL. Disclosure of Interests: None declared.