Sustained remission with etanercept tapering in early rheumatoid arthritis.
BACKGROUND
We assessed the effects of reduction and withdrawal of treatment in patients with rheumatoid arthritis who had a remission while receiving etanercept-plus-methotrexate therapy.


METHODS
Patients with early active disease who had not previously received methotrexate or biologic therapy received 50 mg of etanercept plus methotrexate weekly for 52 weeks (open-label phase). We then randomly assigned patients who had qualifying responses at weeks 39 and 52 to receive 25 mg of etanercept plus methotrexate (combination-therapy group), methotrexate alone, or placebo for 39 weeks (double-blind phase). Patients who had qualifying responses at week 39 of the double-blind phase had all treatment withdrawn at that time and were followed to week 65 (treatment-withdrawal phase). The primary end point was the proportion of patients with sustained remission in the double-blind phase.


RESULTS
Of 306 patients enrolled, 193 underwent randomization in the double-blind phase; 131 qualified for the treatment-withdrawal phase. More patients in the combination-therapy group than in the methotrexate-alone group or the placebo group met the criterion for the primary end point (40 of 63 [63%] vs. 26 of 65 [40%] and 15 of 65 [23%], respectively; P=0.009 for combination therapy vs. methotrexate alone; P<0.001 for combination therapy vs. placebo). At 65 weeks, 28 patients (44%) who had received combination therapy, 19 (29%) who had received methotrexate alone, and 15 (23%) who had received placebo were in remission (P=0.10 for combination therapy vs. methotrexate alone; P=0.02 for combination therapy vs. placebo; P=0.55 for methotrexate alone vs. placebo). No significant between-group differences were observed in radiographic progression of disease. Serious adverse events were reported in 3 patients (5%) in the combination-therapy group, 2 (3%) in the methotrexate-alone group, and 2 (3%) in the placebo group.


CONCLUSIONS
In patients with early rheumatoid arthritis who had a remission while receiving full-dose etanercept-plus-methotrexate therapy, continuing combination therapy at a reduced dose resulted in better disease control than switching to methotrexate alone or placebo, but no significant difference was observed in radiographic progression. (Funded by Pfizer; ClinicalTrials.gov number, NCT00913458.).
From the Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, the Chapel Allerton Hospital, and the National Institute for Health Research Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust - all in Leeds, United Kingdom (P.E., M.H.B.); Hamad Medical, Doha, Qatar (M.H.); St. Vincent's University Hospital, Dublin (O.F.); Rheumatology Department, Lapeyronie Hospital, Montpellier 1 University, Montpellier, France (B.C.); La Paz University Hospital, IdiPaz, Madrid (E.M.-M.); Hospital Health Center of West Mazovia, Rheumatology Department, Żyrardów, Poland (M.K.); and Pfizer, Collegeville, PA (T.W., S.G., R.P., J.B., B.V.).
Paul
P
Emery
Mohammed
M
Hammoudeh
Oliver
O
FitzGerald
Bernard
B
Combe
Emilio
E
Martin-Mola
Maya H
MH
Buch
Marek
M
Krogulec
Theresa
T
Williams
Stefanie
S
Gaylord
Ronald
R
Pedersen
Jack
J
Bukowski
Bonnie
B
Vlahos
D000328:Adult; D000368:Aged; D018501:Antirheumatic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D000068800:Etanercept; D005260:Female; D006801:Humans; D007074:Immunoglobulin G / Q000008:administration & dosage* / Q000009:adverse effects; D007239:Infections / Q000209:etiology; D008297:Male; D008727:Methotrexate / Q000008:administration & dosage* / Q000009:adverse effects; D008875:Middle Aged; D018124:Receptors, Tumor Necrosis Factor / Q000008:administration & dosage*; D012074:Remission Induction; D028761:Withholding Treatment
D018501:Antirheumatic Agents; D007074:Immunoglobulin G; D018124:Receptors, Tumor Necrosis Factor; D000068800:Etanercept; D008727:Methotrexate