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Published in: Trials 1/2022

Open Access 01-12-2022 | Rheumatoid Arthritis | Study protocol

Efficacy and safety of progressively reducing biologic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis in persistent remission: a study protocol for a non-inferiority randomized, controlled, single-blind trial

Authors: Shangwen Lei, Zijia Li, Xiaoli Zhang, Shuhong Zhou

Published in: Trials | Issue 1/2022

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Abstract

Background

To compare the effects of two biologic disease-modifying antirheumatic drug (bDMARD) administration strategies on the maintenance effect and safety of patients with rheumatoid arthritis (RA) in remission, to analyze the effects of gradual drug reduction and dose maintenance treatment on clinical outcomes in patients who have achieved remission with different types of bDMARDs, to search and screen out people who may benefit from drug reduction strategies, and to provide references for drug reduction strategies and treatment options for patients with RA in remission, so as to help improve the safety of the treatment and reduce the economic burden.

Methods

The study will be a 24-month non-inferiority randomized, controlled, single-blind trial and is planned to be launched in our hospital from September 2021 to August 2023. Patients will be randomized in a ratio of 2:1 to two groups: maintenance or injection spacing by 50%/gradual reduction of dosage every 3 months up to complete stop. When the patient relapses, return to the last effective dose. If the remission can be maintained, the medication of bDMARDs can be stopped 9 months after enrollment. The primary outcome will be the persistent flare rate.

Discussion

Our study may provide a reference for the selection of drug reduction strategies and treatment options for patients with RA in remission, so as to help improve the safety of the treatment and reduce the economic burden.

Trial registration

Chinese Clinical Trial Registry ChiCTR2100044751. Registered on 26 March 2021
Literature
1.
2.
go back to reference Escalante A, Haas RW, del Rincon I. A model of impairment and functional limitation in rheumatoid arthritis. BMC Musculoskelet Disord. 2005;6:16.CrossRef Escalante A, Haas RW, del Rincon I. A model of impairment and functional limitation in rheumatoid arthritis. BMC Musculoskelet Disord. 2005;6:16.CrossRef
3.
go back to reference Hulsmans HM, Jacobs JW, van der Heijde DM, van Albada-Kuipers GA, Schenk Y, Bijlsma JW. The course of radiologic damage during the first six years of rheumatoid arthritis. Arthritis Rheum. 2000;43(9):1927–40.CrossRef Hulsmans HM, Jacobs JW, van der Heijde DM, van Albada-Kuipers GA, Schenk Y, Bijlsma JW. The course of radiologic damage during the first six years of rheumatoid arthritis. Arthritis Rheum. 2000;43(9):1927–40.CrossRef
4.
go back to reference Aletaha D, Smolen JS. Diagnosis and management of rheumatoid arthritis: a review. JAMA. 2018;320:1360–72.CrossRef Aletaha D, Smolen JS. Diagnosis and management of rheumatoid arthritis: a review. JAMA. 2018;320:1360–72.CrossRef
5.
go back to reference Cooper NJ. Economic burden of rheumatoid arthritis: a systematic review. Rheumatology (Oxford). 2000;39(1):28–33.CrossRef Cooper NJ. Economic burden of rheumatoid arthritis: a systematic review. Rheumatology (Oxford). 2000;39(1):28–33.CrossRef
6.
go back to reference Singh JA, Saag KG, Bridges SL, Jr77, et al. 2015 American College of Rheumatology Guideline for the treatment of rheumatoid arthritis. Arthritis Rheum 2016;68:1–26. Singh JA, Saag KG, Bridges SL, Jr77, et al. 2015 American College of Rheumatology Guideline for the treatment of rheumatoid arthritis. Arthritis Rheum 2016;68:1–26.
7.
go back to reference McInnes IB, Schett G. The pathogenesis of rheumatoid arthritis. N Engl J Med. 2011;365:2205–19.CrossRef McInnes IB, Schett G. The pathogenesis of rheumatoid arthritis. N Engl J Med. 2011;365:2205–19.CrossRef
8.
go back to reference McInnes IB, Buckley CD, Isaacs JD. Cytokines in rheumatoid arthritis - shaping the immunological landscape. Nat Rev Rheumatol. 2016;12:63–8.CrossRef McInnes IB, Buckley CD, Isaacs JD. Cytokines in rheumatoid arthritis - shaping the immunological landscape. Nat Rev Rheumatol. 2016;12:63–8.CrossRef
9.
go back to reference Smolen JS, Landewé R, Breedveld FC, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis. 2010;69:964–75.CrossRef Smolen JS, Landewé R, Breedveld FC, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis. 2010;69:964–75.CrossRef
10.
go back to reference Aga AB, Lie E, Uhlig T, et al. Time trends in disease activity, response and remission rates in rheumatoid arthritis during the past decade: results from the NOR-DMARD study 2000-2010. Ann Rheum Dis. 2015;74:381–8.CrossRef Aga AB, Lie E, Uhlig T, et al. Time trends in disease activity, response and remission rates in rheumatoid arthritis during the past decade: results from the NOR-DMARD study 2000-2010. Ann Rheum Dis. 2015;74:381–8.CrossRef
11.
go back to reference Fautrel B, Den Broeder AA. De-intensifying treatment in established rheumatoid arthritis (RA): why, how, when and in whom can DMARDs be tapered? Best Pract Res Clin Rheumatol. 2015;29:550–65.CrossRef Fautrel B, Den Broeder AA. De-intensifying treatment in established rheumatoid arthritis (RA): why, how, when and in whom can DMARDs be tapered? Best Pract Res Clin Rheumatol. 2015;29:550–65.CrossRef
12.
go back to reference Haschka J, Englbrecht M, Hueber AJ, et al. Relapse rates in patients with rheumatoid arthritis in stable remission tapering or stopping antirheumatic therapy: interim results from the prospective randomised controlled RETRO study. Ann Rheum Dis. 2016;75:45–51.CrossRef Haschka J, Englbrecht M, Hueber AJ, et al. Relapse rates in patients with rheumatoid arthritis in stable remission tapering or stopping antirheumatic therapy: interim results from the prospective randomised controlled RETRO study. Ann Rheum Dis. 2016;75:45–51.CrossRef
13.
go back to reference Arnett FC, Edworthy SM, Bloch DA, et al. The American rheumatism association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988;31:315–24.CrossRef Arnett FC, Edworthy SM, Bloch DA, et al. The American rheumatism association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988;31:315–24.CrossRef
14.
go back to reference Aletaha D, Neogi T, Silman AJ, et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European league against rheumatism collaborative initiative. Ann Rheum Dis. 2010;69:1580–8.CrossRef Aletaha D, Neogi T, Silman AJ, et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European league against rheumatism collaborative initiative. Ann Rheum Dis. 2010;69:1580–8.CrossRef
15.
go back to reference Bouman CA, van Herwaarden N, van den Hoogen FH, et al. Long-term outcomes after disease activity-guided dose reduction of TNF inhibition in rheumatoid arthritis: 3-year data of the DRESS study - a randomised controlled pragmatic non-inferiority strategy trial. Ann Rheum Dis. 2017;76:1716–22.CrossRef Bouman CA, van Herwaarden N, van den Hoogen FH, et al. Long-term outcomes after disease activity-guided dose reduction of TNF inhibition in rheumatoid arthritis: 3-year data of the DRESS study - a randomised controlled pragmatic non-inferiority strategy trial. Ann Rheum Dis. 2017;76:1716–22.CrossRef
16.
go back to reference van der Maas A, Lie E, Christensen R, et al. Construct and criterion validity of several proposed DAS28-based rheumatoid arthritis flare criteria: an OMERACT cohort validation study. Ann Rheum Dis. 2013;72:1800.CrossRef van der Maas A, Lie E, Christensen R, et al. Construct and criterion validity of several proposed DAS28-based rheumatoid arthritis flare criteria: an OMERACT cohort validation study. Ann Rheum Dis. 2013;72:1800.CrossRef
17.
go back to reference Burmester GR, Buttgereit F, Bernasconi C, et al. Continuing versus tapering glucocorticoids after achievement of low disease activity or remission in rheumatoid arthritis (SEMIRA): a double-blind, multicentre, randomised controlled trial. Lancet. 2020;396:267–76.CrossRef Burmester GR, Buttgereit F, Bernasconi C, et al. Continuing versus tapering glucocorticoids after achievement of low disease activity or remission in rheumatoid arthritis (SEMIRA): a double-blind, multicentre, randomised controlled trial. Lancet. 2020;396:267–76.CrossRef
18.
go back to reference van Gestel AM, Haagsma CJ, van Riel PL. Validation of rheumatoid arthritis improvement criteria that include simplified joint counts. Arthritis Rheum. 1998;41:1845–50.CrossRef van Gestel AM, Haagsma CJ, van Riel PL. Validation of rheumatoid arthritis improvement criteria that include simplified joint counts. Arthritis Rheum. 1998;41:1845–50.CrossRef
19.
go back to reference van der Heijde D. How to read radiographs according to the sharp/van der Heijde method. J Rheumatol. 2000;27:261–3.PubMed van der Heijde D. How to read radiographs according to the sharp/van der Heijde method. J Rheumatol. 2000;27:261–3.PubMed
20.
go back to reference Fautrel B, Pham T, Alfaiate T, et al. Step-down strategy of spacing TNF-blocker injections for established rheumatoid arthritis in remission: results of the multicentre non-inferiority randomised open-label controlled trial (STRASS: spacing of TNF-blocker injections in rheumatoid ArthritiS study). Ann Rheum Dis. 2016;75:59–67.CrossRef Fautrel B, Pham T, Alfaiate T, et al. Step-down strategy of spacing TNF-blocker injections for established rheumatoid arthritis in remission: results of the multicentre non-inferiority randomised open-label controlled trial (STRASS: spacing of TNF-blocker injections in rheumatoid ArthritiS study). Ann Rheum Dis. 2016;75:59–67.CrossRef
21.
go back to reference Fries JF, Spitz PW, Young DY. The dimensions of health outcomes: the health assessment questionnaire, disability and pain scales. J Rheumatol. 1982;9:789–93.PubMed Fries JF, Spitz PW, Young DY. The dimensions of health outcomes: the health assessment questionnaire, disability and pain scales. J Rheumatol. 1982;9:789–93.PubMed
22.
go back to reference ten Wolde S, Breedveld FC, Hermans J, et al. Randomised placebo-controlled study of stopping second-line drugs in rheumatoid arthritis. Lancet. 1996;347:347–52.CrossRef ten Wolde S, Breedveld FC, Hermans J, et al. Randomised placebo-controlled study of stopping second-line drugs in rheumatoid arthritis. Lancet. 1996;347:347–52.CrossRef
23.
go back to reference Smolen JS, Breedveld FC, Burmester GR, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis. 2016;75:3–15.CrossRef Smolen JS, Breedveld FC, Burmester GR, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis. 2016;75:3–15.CrossRef
24.
go back to reference Brocq O, Millasseau E, Albert C, et al. Effect of discontinuing TNFalpha antagonist therapy in patients with remission of rheumatoid arthritis. Joint Bone Spine. 2009;76:350–5.CrossRef Brocq O, Millasseau E, Albert C, et al. Effect of discontinuing TNFalpha antagonist therapy in patients with remission of rheumatoid arthritis. Joint Bone Spine. 2009;76:350–5.CrossRef
25.
go back to reference Smolen JS, Emery P, Ferraccioli GF, et al. Certolizumab pegol in rheumatoid arthritis patients with low to moderate activity: the CERTAIN double-blind, randomised, placebo-controlled trial. Ann Rheum Dis. 2015;74:843–50.CrossRef Smolen JS, Emery P, Ferraccioli GF, et al. Certolizumab pegol in rheumatoid arthritis patients with low to moderate activity: the CERTAIN double-blind, randomised, placebo-controlled trial. Ann Rheum Dis. 2015;74:843–50.CrossRef
26.
go back to reference Weinblatt ME, Bingham CO 3rd, Burmester GR, et al. A phase III study evaluating continuation, tapering, and withdrawal of certolizumab pegol after one year of therapy in patients with early rheumatoid arthritis. Arthritis Rheum. 2017;69:1937–48.CrossRef Weinblatt ME, Bingham CO 3rd, Burmester GR, et al. A phase III study evaluating continuation, tapering, and withdrawal of certolizumab pegol after one year of therapy in patients with early rheumatoid arthritis. Arthritis Rheum. 2017;69:1937–48.CrossRef
27.
go back to reference Henaux S, Ruyssen-Witrand A, Cantagrel A, et al. Risk of losing remission, low disease activity or radiographic progression in case of bDMARD discontinuation or tapering in rheumatoid arthritis: systematic analysis of the literature and meta-analysis. Ann Rheum Dis. 2018;77:515–22.CrossRef Henaux S, Ruyssen-Witrand A, Cantagrel A, et al. Risk of losing remission, low disease activity or radiographic progression in case of bDMARD discontinuation or tapering in rheumatoid arthritis: systematic analysis of the literature and meta-analysis. Ann Rheum Dis. 2018;77:515–22.CrossRef
Metadata
Title
Efficacy and safety of progressively reducing biologic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis in persistent remission: a study protocol for a non-inferiority randomized, controlled, single-blind trial
Authors
Shangwen Lei
Zijia Li
Xiaoli Zhang
Shuhong Zhou
Publication date
01-12-2022
Publisher
BioMed Central
Published in
Trials / Issue 1/2022
Electronic ISSN: 1745-6215
DOI
https://doi.org/10.1186/s13063-022-06543-y

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