Almost half of patients with RA who discontinue TNF inhibitor treatment after achieving remission will relapse, a meta-analysis by Australian authors shows.

A systematic review of 16 randomised controlled trials of elective discontinuation of TNFis in RA patients in remission  found an overall relapse rate of 47%. The duration of follow-up after withdrawal was over 12 months in 12 studies, and less than 12 months in the remaining four studies.

The review authors, led by Dr Arduino Mangoni of the Department of Clinical Pharmacology at Flinders University, Adelaide, said the observed relapse rate was higher than seen in previous reviews, which had also included studies with dose tapering.

They said the review provided important information for RA patients in remission, many of whom may be considering discontinuation due to factors such as adverse effects, cost or lack of efficacy.

“The availability of robust data regarding the relapse rate in [RA patients in remission] might assist with treatment decisions, as well as informing future guidelines on RA management. This is particularly so as TNF-α inhibitor withdrawal is particularly common in clinical practice,” they wrote in in BMC Rheumatology.

“Our study shows that elective TNF-α inhibitor withdrawal in RA patients is associated with a relatively high relapse rate. This information should be taken into account when considering this management strategy,” they said.

However, they noted that the review did not identify specific patient or treatment characteristics associated with the risk of relapse.

“Professional guidelines do not provide clear recommendations regarding management strategies once remission, or stable low disease activity, is achieved,” they wrote.

“Similarly, there is a limited amount of evidence regarding whether, when, how and in whom TNF-α inhibitors can be safely and effectively withdrawn …”.