Occurrence and prediction of flare after tapering of TNF inhibitors in patients with axial spondyloarthritis.

Oct 16, 2023

Experts: Marie Wetterslev,Stylianos Georgiadis,Sara Nysom Christiansen,Susanne Juhl Pedersen,Inge Juul Sørensen,Merete Lund Hetland,Anne Duer,Mikael Boesen,Kasper Kjærulf Gosvig,Jakob Møllenbach Møller,Mads Bakkegaard,Cecilie Heegaard Brahe,Niels Steen Krogh,Bente Jensen,Ole Rintek Madsen,Jan Christensen,Annette Hansen,Jesper Nørregaard,Henrik Røgind,Mikkel Østergaard

Patients with axial spondyloarthritis (axSpA) in clinical remission tapered Tumor Necrosis Factor inhibitor (TNFi) therapy according to a clinical guideline. During 2-years’ follow-up, we aimed to investigate flare frequency, dose at which flare occurred, type of flare and predictors thereof.
Patients in clinical remission (Bath ankylosing spondylitis disease activity index (BASDAI)<40, physician global score<40 and without disease activity the previous year) tapered TNFi to 2/3 standard dose at baseline, 1/2 at week (w) 16, 1/3 at w32 and discontinuationed at w48. Flare was defined as: BASDAI flare (BASDAI≥40 and Δ≥20) and/or clinical flare (development of inflammatory back pain, musculoskeletal or extra-articular manifestations and/or ASDAS-CRP increase ≥0.9) and/or MRI flare (≥2 new/worsened inflammatory lesions).
Of 108 patients, 106 (99%) flared before 2 years: 29 patients (27%) at 2/3 standard dose, 21 (20%) at 1/2 dose, 29 (27%) at 1/3 dose and 27 (25%) after discontinuation. One-hundred-and-five (99%) had clinical flare, 25 (24%) BASDAI flare and 23 (29% of patients with MRI) MRI flare. Forty-one patients (41%) fulfilled the ASAS-definition of clinically important worsening (≥0.9 increase since baseline). Higher baseline physician global score was an independent predictor of flare after tapering to 2/3 (Odds ratio=1.19 (95% Confidence Interval=1.05-1.41);p=0.011). Changes in clinical and/or imaging variables in the 16 weeks prior to tapering did not predict flare.
Almost all (99%) axSpA patients in clinical remission flared during tapering to discontinuation, but above half not before receiving 1/3 dose or less. Higher physician global score was an independent predictor of flare.

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ABOUT THE EXPERTS

Marie Wetterslev,Stylianos Georgiadis,Sara Nysom Christiansen,Susanne Juhl Pedersen,Inge Juul Sørensen,Merete Lund Hetland,Anne Duer,Mikael Boesen,Kasper Kjærulf Gosvig,Jakob Møllenbach Møller,Mads Bakkegaard,Cecilie Heegaard Brahe,Niels Steen Krogh,Bente Jensen,Ole Rintek Madsen,Jan Christensen,Annette Hansen,Jesper Nørregaard,Henrik Røgind,Mikkel Østergaard

Marie Wetterslev

Marie Wetterslev, MD PhD, Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Rigshospitalet, Glostrup, Denmark.

Stylianos Georgiadis

Stylianos Georgiadis, PhD, Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Rigshospitalet, Glostrup, Denmark.

Sara Nysom Christiansen

Sara Nysom Christiansen, MD PhD, Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Rigshospitalet, Glostrup, Denmark.

Susanne Juhl Pedersen

Susanne Juhl Pedersen, MD PhD, Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Rigshospitalet, Glostrup, Denmark.

Inge Juul Sørensen

Inge Juul Sørensen, MD PhD, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark.

Merete Lund Hetland

Merete Lund Hetland, MD PhD DMSc, Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark; The DANBIO Registry, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Rigshospitalet, Glostrup, Denmark.

Anne Duer

Anne Duer, MD PhD, Department of Radiology, Rigshospitalet, Glostrup, Copenhagen, Denmark.

Mikael Boesen

Mikael Boesen, MD PhD DMSc, Department of Radiology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.

Kasper Kjærulf Gosvig

Kasper Kjærulf Gosvig, MD PhD, Department of Radiology, Herlev and Gentofte Hospital, Copenhagen, Denmark.

Jakob Møllenbach Møller

Jakob Møllenbach Møller, PhD, Department of Radiology, Herlev and Gentofte Hospital, Copenhagen, Denmark.

Mads Bakkegaard

Mads Bakkegaard, MD, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Rigshospitalet, Glostrup, Denmark.

Cecilie Heegaard Brahe

Cecilie Heegaard Brahe, MD PhD, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Frederiksberg and Bispebjerg Hospital, Copenhagen, Denmark.

Niels Steen Krogh

Niels Steen Krogh, Zitelap Aps, Copenhagen, Denmark.

Bente Jensen

Bente Jensen, MD PhD, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Frederiksberg and Bispebjerg Hospital, Copenhagen, Denmark.

Ole Rintek Madsen

Ole Rintek Madsen, MD PhD, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Herlev and Gentofte Hospital, Copenhagen, Denmark.

Jan Christensen

Jan Christensen, MD, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Frederiksberg and Bispebjerg Hospital, Copenhagen, Denmark.

Annette Hansen

Annette Hansen, MD, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Herlev and Gentofte Hospital, Copenhagen, Denmark.

Jesper Nørregaard

Jesper Nørregaard, MD PhD, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Rigshospitalet, Glostrup, Denmark.

Henrik Røgind

Henrik Røgind, MD PhD, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Rigshospitalet, Glostrup, Denmark.

Mikkel Østergaard

Mikkel Østergaard, MD, PhD, DMSc, Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, University Hospital of Copenhagen, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark.