Department of Rheumatology, Aalborg University Hospital.
Department of Clinical Medicine, Aalborg University, Aalborg.
Rheumatology (Oxford). 2022 Aug 3;61(8):3107-3122. doi: 10.1093/rheumatology/keab902.
To evaluate flare risk when tapering or withdrawing biologic or targeted synthetic DMARDs (bDMARDs or tsDMARDs) compared with continuation in patients with inflammatory arthritis in sustained remission or with low disease activity.
Articles were identified in the Cochrane Library, PubMed, Embase and Web of Science. Eligible trials were randomized controlled trials comparing tapering and/or withdrawal of bDMARDs and/or tsDMARDs with the standard dose in inflammatory arthritis. Random effects meta-analysis was performed with risk ratio (RR) or Peto's odds ratio (POR) for sparse events and 95% CI.
The meta-analysis comprised 22 trials: 11 assessed tapering and 7 addressed withdrawal (4 assessed both). Only trials with an RA or axial SpA (axSpA) population were identified. An increased flare risk was demonstrated when b-/tsDMARD tapering was compared with continuation [RR 1.45 (95% CI 1.19, 1.77), I2 = 42.5%] and potentially increased for persistent flare [POR 1.56 (95% CI 0.97, 2.52), I2 = 0%]. Comparing TNF inhibitor (TNFi) withdrawal with continuation, a highly increased flare risk [RR 2.28 (95% CI 1.78, 2.93), I2 = 78%] and increased odds of persistent flare [POR 3.41 (95% CI 1.91, 6.09), I2 = 49%] were observed. No clear difference in flare risk between RA or axSpA was observed.
A high risk for flare and persistent flare was demonstrated for TNFi withdrawal, whereas an increased risk for flare but not for persistent flare was observed for b-/tsDMARD tapering. Thus tapering seems to be the more favourable approach.
PROSPERO (CRD42019136905).
评估在炎症性关节炎患者持续缓解或低疾病活动度时，与继续使用生物制剂或靶向合成疾病修正抗风湿药物（bDMARD 或 tsDMARD）相比，逐渐减少或停用这些药物时的发作风险。
在 Cochrane 图书馆、PubMed、Embase 和 Web of Science 中检索文献。合格的试验是比较炎症性关节炎中逐渐减少和/或停用 bDMARD 和/或 tsDMARD 与标准剂量的随机对照试验。对于稀疏事件，采用风险比（RR）或 Peto 的优势比（POR）进行随机效应荟萃分析，并给出 95%置信区间。
荟萃分析包括 22 项试验：11 项评估了逐渐减少，7 项评估了停药（4 项同时评估了逐渐减少和停药）。仅确定了具有类风湿关节炎或中轴型脊柱关节炎（axSpA）人群的试验。与继续治疗相比，b-/tsDMARD 逐渐减少会增加发作风险[RR 1.45（95%CI 1.19，1.77），I2=42.5%]，且持续性发作的风险可能增加[POR 1.56（95%CI 0.97，2.52），I2=0%]。与继续治疗相比，比较 TNF 抑制剂（TNFi）停药，会增加发作风险[RR 2.28（95%CI 1.78，2.93），I2=78%]和持续性发作的可能性[POR 3.41（95%CI 1.91，6.09），I2=49%]。RA 或 axSpA 之间的发作风险无明显差异。
TNFi 停药会导致高发作和持续性发作风险，而 b-/tsDMARD 逐渐减少则会增加发作风险，但不会增加持续性发作风险。因此，逐渐减少似乎是更有利的方法。
PROSPERO（CRD42019136905）。
