Optimizing withdrawal strategies for anti-TNF-α therapies in rheumatoid arthritis

ABSTRACT

Introduction

Rheumatoid arthritis (RA) is a chronic autoimmune disease that significantly impacts patients’ quality of life. While treatment options have expanded over the years, including the introduction of tumor necrosis factor-alpha (TNFα) inhibitors (TNFi), optimizing withdrawal strategies for these agents remains a challenge.

Areas covered

This review examines the current evidence on TNFi withdrawal strategies in RA, focusing on factors influencing withdrawal decisions such as disease activity monitoring, treatment response, patient characteristics, and biomarkers. A comprehensive literature search was conducted, including randomized controlled trials, observational studies, and expert guidelines. The pathophysiology of RA, current pharmacological agents, and the treat-to-target strategy are discussed to provide a holistic understanding of RA management.

Expert opinion

Withdrawal strategies could be suitable for certain patients, keeping in mind that several factors influence withdrawal decisions, including treatment response, disease activity and monitoring, and patient characteristics. The decision to withdraw TNFi must balance the benefits against the potential risks of disease flare and long-term treatment-related adverse effects. Combining DMARDs and TNFi early improves outcomes, supporting tapering strategies for cost-effectiveness and flare prevention. Future directions, including precision medicine approaches, patient-centered care models, and health economics analyses, are proposed to further optimize RA management and improve patient outcomes.

KEYWORDS:

• Rheumatoid arthritis
• biological treatment
• tumor necrosis factor-alpha inhibitors
• withdrawal
• dosage reduction

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Article Highlights

• T2T strategies prioritize early intervention and aggressive inflammation control for better outcomes.

• Implementing T2T is necessary for managing RA patients, especially after TNFi discontinuation.

• Tapering TNFi through dosage reduction is a balanced cost-effectiveness and risk-minimization approach.

• Full-dose TNFi can be re-administered to RA patients who relapse to regain remission.

• Physician collaboration is essential for advancing RA management through precision medicine, outcome studies, and health economics analyses.

Declaration of Interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

ADA: Adalimumab, CR: clinical remission, DAS28: 28-joint disease activity score, ETN: Etanercept, ESR: Erythrocyte Sedimentation Rate, MTX: Methotrexate, IFX: Infliximab, LDA: low disease activity

Additional information

Funding

This paper was not funded