Tocilizumab discontinuation in RA feasible after remission achievement
Discontinuation of tocilizumab in rheumatoid arthritis (RA) patients who have achieved remission is feasible with continued methotrexate (MTX) therapy, according to 2-year data from the SURPRISE study. Moreover, retreatment with tocilizumab is effective for suppressing flares with or without MTX.
The current analysis included 102 patients who ceased tocilizumab treatment after achieving remission in the first year (week 52). Of these patients, 49 continued MTX (mean age 57.5 years; 90 percent female) and 53 received no disease-modifying antirheumatic drugs (DMARDs; mean age 54.4 years; 89 percent female).
At week 104, significantly more patients in the MTX group than in the no-DMARDs group sustained low disease activity (disease activity score for 28 joints–erythrocyte sedimentation rate <2.6; 55 percent vs 27 percent; p=0.005). [Ann Rheum Dis 2018;doi:10.1136/annrheumdis-2018-213416]
Conversely, no between-group differences were seen in sustained remission rates (24 percent in the MTX group vs 14 percent in the no-DMARDS group; p=0.29) and radiological progression (modified total Sharp score, 0.37 vs 0.64, respectively; p=0.36).
Between weeks 52 and 104, 16 patients (32.7 percent) in the MTX group restarted tocilizumab because of flare. In the no-DMARDS group, 35 (66.0 percent) restarted treatment with MTX (n=12), tocilizumab (n=18) or a combination of both (n=5). The median time from tocilizumab discontinuation to treatment restart was 16 weeks in the MTX group and 14, 16 and 8 weeks in the no-DMARDs group with MTX, tocilizumab and MTX plus tocilizumab, respectively.
Overall, tocilizumab retreatment led to remission in 91.3 percent of patients, with its efficacy independent of concomitant MTX.
In terms of safety, adverse events (AEs) tended to be higher in the MTX group than in the no-DMARDs group, with gastrointestinal disorder (18.4 percent vs 0 percent) including oral ulcer and abdominal pain being the most commonly reported.
“[O]ur study suggests that stopping tocilizumab after remission achievement is worth attempting, in that retaining MTX is better for maintaining low disease activity. In addition, [it emphasizes anew] the results of the first year of the SURPRISE study [wherein] tocilizumab induction would be recommended in combination with MTX in patients inadequately responsive but tolerant to MTX,” the authors pointed out.
“However, it should be noted that continued MTX caused more adverse events, especially gastrointestinal symptoms... The optimal dose of continued MTX is another issue that requires clarification,” they added.
The authors acknowledged the presence of several study limitations, including the open-label design and limited number of participants. There also was a lack of data on anticitrullinated antibody, and the small sample size prevented the identification of predictive factors for successful tocilizumab-free remission or low disease activity.