title: Down-titration and discontinuation of infliximab in rheumatoid arthritis patients with stable low disease activity and stable treatment: an observational cohort study.
abstract: Down-titration, or discontinuing infliximab, has proven to be feasible in RA patients. Therefore, our local treatment protocol includes tapering infliximab dose. This observational study describes the prevalence of successful down-titration in daily clinical practice and its effect on costs and quality of life (QoL).
  
  
  METHODS
  Infliximab was down-titrated with 25% of the original dose (3 mg/kg) every 8-12 weeks without interval change until discontinuation or flare in all RA patients with stable low 28-joint disease activity score (DAS28) and stable treatment for >6 months. During 1 year DAS28, RA medication, outpatient clinic visits, RA related absenteeism and EuroQoL5D (European QoL questionnaire, EQ5D) were documented. Prevalence of successful down-titration and changes in DAS28, QoL and costs were described.
  
  
  RESULTS
  In 16% (95% CI 6 to 26) and 45% (95% CI 31 to 59), respectively, infliximab could be discontinued or down-titrated. Mean infliximab dose decreased significantly from 224 mg (95% CI 212 to 236 mg) at start, to 130 mg (95% CI 105 to 154 mg) after 1 year. Median DAS28 increased from 2.5 (p25-75=2.0-2.9) to 2.8 (2.2-3.6) (p=0.002). Extra corticosteroids were given in 8% of the visits. Disease modifying antirheumatic drugs were seldom changed. There was no statistical difference in QoL after down-titration. Mean reduction in the costs was €3474 (95% CI 2457 to 4492) per patient.
  
  
  CONCLUSIONS
  In the majority of patients with stable low DAS28 and stable treatment, infliximab can be down-titrated or discontinued, which results in a considerable reduction in costs without influencing QoL.
authors.affiliation: Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, Postbus 9011, Nijmegen 6500 GM, The Netherlands. vandermaas@maartenskliniek.nl
authors.forename: Aatke
authors.initials: A
authors.lastname: van der Maas
authors.forename: Wietske
authors.initials: W
authors.lastname: Kievit
authors.forename: Bart J F
authors.initials: BJ
authors.lastname: van den Bemt
authors.forename: Frank H J
authors.initials: FH
authors.lastname: van den Hoogen
authors.forename: Piet L
authors.initials: PL
authors.lastname: van Riel
authors.forename: Alfons A
authors.initials: AA
authors.lastname: den Broeder
mesh_terms: D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D015331:Cohort Studies; D004305:Dose-Response Relationship, Drug; D016903:Drug Monitoring / Q000379:methods; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D000069285:Infliximab; D007596:Joints / Q000473:pathology; D008297:Male; D008875:Middle Aged; D012074:Remission Induction; D012720:Severity of Illness Index; D013997:Time Factors; D028761:Withholding Treatment
chemical_list: D000911:Antibodies, Monoclonal; D018501:Antirheumatic Agents; D000069285:Infliximab