Efficacy of Reduced Dose Tumor Necrosis Factor Inhibitors in Axial Spondyloarthritis
The introduction of tumor necrosis factor inhibitors marked a breakthrough in the treatment of axial spondyloarthritis and other autoimmune diseases. One disadvantage of using these drugs can be increased susceptibility of patients to various infectious agents. The aim of the presented meta-analysis was therefore to determine whether a reduced dose of TNF inhibitors provides the same efficacy with a more favorable safety profile compared to the standard dosing regimen.
Introduction
Axial spondyloarthritis is a collective term for the form of the disease without radiological findings and the form of the disease with typical radiological changes, also known as ankylosing spondylitis.
In recent years, two major changes have occurred in the diagnosis and treatment of the disease. The first change is the routine use of magnetic resonance imaging (MRI) in the diagnosis of the disease, enabling earlier diagnosis in many cases. The second change is the introduction of targeted anti-inflammatory treatment in the form of tumor necrosis factor (TNF) inhibitors into routine medical practice. Modern treatment significantly improves the quality of life of patients, alleviates symptoms, and slows the progression of the disease. However, an inherent disadvantage of administering TNF inhibitors is the increased susceptibility of patients to various infectious agents.
Objectives of the Analysis
The meta-analysis included a total of 6 clinical studies with 747 patients (442 with the radiographic form, and 305 with the non-radiographic form of the disease). The primary objectives of the meta-analysis were to evaluate treatment response, remission, disease activity, relapse, and therapy safety using criteria developed by the Assessment in SpondyloArthritis international Society (ASAS).
Findings
Among patients using a reduced dose of TNF inhibitors, fewer met ASAS criteria for at least a 40% improvement in clinical status (relative risk [RR] 0.62; 95% CI 0.49–0.78) and partial remission (RR 0.17; 95% CI 0.06–0.46). Patients on the reduced dose experienced an average increase in the Bath Ankylosing Spondylitis Disease Activity Index score (mean difference 0.35; 95% CI 0.10–0.60), with no significant difference in CRP levels between the groups (mean difference 0.16; 95% CI –0.76 to 1.07).
Conversely, patients on the reduced dose experienced more relapses and disease flares (RR 1.73; 95% CI 1.32–2.27), with no significant difference in infection rates (incidence rate ratio [IRR] 0.98; 95% CI 0.76–1.25) or injection/infusion site reactions (IRR 0.71; 95% CI 0.42–1.19) between the groups.
Summary and Conclusion
The results of the meta-analysis indicate that administering a reduced dose of tumor necrosis factor inhibitors did not reduce infectious complications; on the contrary, more relapses and disease flares were observed. Thus, dose reduction in patients with axial spondyloarthritis does not provide any benefit according to the meta-analysis results.
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Source: Lawson D. O., Eraso M., Mbuagbaw L et al. Tumour necrosis factor inhibitor dose reduction for axial spondyloarthritis: a systematic review and meta-analysis of randomized controlled trials. Arthritis Care Res (Hoboken) 2020 Mar 12, doi: 10.1002/acr.24184 [Epub ahead of print].
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