Meng Charis F, Rajesh Diviya A, Jannat-Khah Deanna P, Jivanelli Bridget, Bykerk Vivian P
C.F. Meng MD, V.P. Bykerk, MD, Division of Rheumatology, Hospital for Special Surgery, and Department of Medicine, Weill Cornell Medical College.
D.A. Rajesh, BA, Division of Rheumatology, Hospital for Special Surgery.
J Rheumatol. 2023 Jan;50(1):36-47. doi: 10.3899/jrheum.220152. Epub 2022 Aug 15.
To determine the risk of not being able to sustain remission after tapering methotrexate (MTX) from targeted therapy in patients with controlled rheumatoid arthritis (RA).
A systematic literature search was conducted in MEDLINE, Embase, and the Cochrane Library for studies reporting remission outcomes after tapering MTX from targeted therapies in RA. Full-text articles and abstracts reported in English were included. Metaanalyses were conducted using random-effects models. Forest and funnel plots were created.
A total of 10 articles were included. Studies evaluated MTX being tapered from combination treatment with tumor necrosis factor inhibitors, tocilizumab, abatacept, and tofacitinib. A total of 9 studies used a randomized design and 1 was observational. Out of 10 studies, 3 focused on early RA (ie, < 1 yr). The MTX-tapering strategy was gradual in 2 studies and rapid in 8 studies. Follow-up ranged from 3 to 18 months in randomized trials and up to 3 years in the observational study. Our metaanalysis, which included 2000 participants with RA from 10 studies, showed that patients who tapered MTX from targeted therapy had a 10% reduction in the ability to sustain remission and an overall pooled risk ratio of 0.90 (95% CI 0.84-0.97). There was no heterogeneity ( = 0%, = 0.94). Our funnel plot indicated minimal publication bias.
Patients with controlled RA may taper MTX from targeted therapy with a 10% reduction in the ability to sustain remission for up to 18 months. Longer follow-up studies with attention to radiographic, functional, and patient-reported outcomes are needed. The risk of disease worsening should be discussed with the patient with careful follow-up and prompt retreatment of disease worsening.
确定类风湿关节炎（RA）病情得到控制的患者在从靶向治疗中逐渐减少甲氨蝶呤（MTX）用量后无法维持病情缓解的风险。
在MEDLINE、Embase和Cochrane图书馆进行系统文献检索，查找关于RA患者从靶向治疗中逐渐减少MTX用量后缓解结局的研究。纳入以英文报道的全文文章和摘要。采用随机效应模型进行荟萃分析。绘制森林图和漏斗图。
共纳入10篇文章。研究评估了MTX从与肿瘤坏死因子抑制剂、托珠单抗、阿巴西普和托法替布联合治疗中逐渐减量的情况。共有9项研究采用随机设计，1项为观察性研究。在10项研究中，3项关注早期RA（即<1年）。2项研究中MTX逐渐减量策略为逐渐减量，8项研究为快速减量。随机试验的随访时间为3至18个月，观察性研究的随访时间长达3年。我们的荟萃分析纳入了10项研究中的2000例RA患者，结果显示从靶向治疗中逐渐减少MTX用量的患者维持缓解的能力降低了10%，总体合并风险比为0.90（95%CI 0.84 - 0.97）。无异质性（I² = 0%，P = 0.94）。我们的漏斗图显示发表偏倚最小。
病情得到控制的RA患者从靶向治疗中逐渐减少MTX用量时，维持缓解的能力可能降低10%，长达18个月。需要进行更长时间的随访研究，并关注影像学、功能和患者报告的结局。应与患者讨论疾病恶化的风险，并进行仔细随访，一旦疾病恶化应及时重新治疗。
