Up to 50% of patients with nrAxSpA can withdraw TNFi and remain in remission

Many patients with non-radiographic axial spondyloarthritis (nrAxSpA ) can successfully withdraw adalimumab treatment if they achieve sustained clinical remission, a randomised controlled trial shows.

However not all patients who stop TNF inhibitor treatment and then flare will be able to regain clinical remission, according to results from the ABILITY-3 trial.

It is also not possible to predict which patients are likely to remain in drug free remission after withdrawing from treatment, the study published in The Lancet showed.

The multicentre study carried out in 20 countries initially enrolled 673 adult patients with nrAxSpA, of whom 305 (45%) achieved sustained remission after 24 weeks with adalimumab.  Patients in remission were then randomised to 40 weeks of double blind treatment with either continued adlimumab or placebo.

After follow up for a further 68 weeks, almost half the patients who withdrew from adalimumab (47%, 72/153) remained in drug free remission and did not experience a flare compared to 70% (107/152) of those who remained on treatment.

Of the patients who experienced a flare after withdrawal, 57% regained inactive disease status (as defined by ASDAS criteria) after rescue treatment with open label adalimumab.

Thus 70% of patients in remission who discontinued adalimumab did not experience a flare or achieved an inactive disease state after retreatment, a commentary accompanying the study noted.

The authors said withdrawal of TNF inhibitor treatment was an important consideration  for patients who experienced adverse events included nasopharyngitis (16%) and upper respiratory tract infections (13%).

However there was little information available to identify which patients likely to remain in remission after withdrawal of the TNF inhibitor, they noted. Only a very low ASDAS (0-1.3) at week 28 predicted remission maintenance in the study.

“Other predictive parameters were inconsistent and varied with the definition of remission used, suggesting it is not currently possible to reliably predict which patients will do well after treatment withdrawal,” they noted.

Nevertheless, they said the trial provided important information as the first adequately powered study to evaluate the effect of TNF inhibitor treatment withdrawal in maintaining remission, they said.

And while continuation of treatment led to better clinical outcomes, stopping TNF inhibitors was an option that should be discussed between patients and physicians, they suggested.

“With almost 50% of patients achieving drug-free remission, the health system could possibly save a lot of money,” the commentary by Professor Jurgen Braun of the Department of Rheumatology, Ruhr University Bochum, Germany noted.

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