title: Tapering and discontinuation of TNF-α blockers without disease relapse using ultrasonography as a tool to identify patients with rheumatoid arthritis in clinical and histological remission.
abstract: BACKGROUND
  In this study, we assessed whether clinical and ultrasonography (US)-based remission could be used to select patients with rheumatoid arthritis (RA) eligible to taper and discontinue anti-TNF-α therapy after achievement of remission, looking at disease relapse.
  
  
  METHODS
  Forty-two patients with RA in sustained remission who were receiving anti-TNF-α treatment (Disease Activity Score <1.6 at three visits 3 months apart) underwent US evaluation of synovial hypertrophy (SH) and power Doppler (PD) signal presence. Five SH+/PD- patients with RA underwent US-guided knee synovial tissue biopsy to assess histological features of residual synovitis (CD68, CD3 and CD20 immunostaining) after sustained clinical remission was achieved. All patients were enrolled to taper first then discontinue anti-TNF-α. They were followed every 3 months afterwards, and the relapse rate was recorded.
  
  
  RESULTS
  Selected SH+/PD- patients showed low-grade synovitis as demonstrated by the presence of CD68+ cells in the lining layer and few infiltrating CD3+ and CD20+ cells at the time sustained clinical remission was achieved. After anti-TNF-α tapering, 13 patients (30.9 %) relapsed and 29 (69.1 %) SH+/PD- patients maintained disease remission after 3 months and discontinued anti-TNF-α treatment. Among them, 26 patients (89.7 %) maintained disease remission status after 6 months of follow-up. All patients who relapsed were retreated with the previous biologic, following the last effective therapeutic regimen, again reaching a good European League Against Rheumatism response within 3 months.
  
  
  CONCLUSIONS
  US evaluation using PD signalling allows the identification of patients with RA in clinical and histological remission after tapering and discontinuing biologics.
authors: Institute of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy. stefano.alivernini@hotmail.it.
authors: Stefano
authors: S
authors: Alivernini
authors: Institute of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy. giusy.peluso@h-columbus.it.
authors: Giusy
authors: G
authors: Peluso
authors: Institute of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy. annalaurafedele@gmail.com.
authors: Anna Laura
authors: AL
authors: Fedele
authors: Institute of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy. barbara.tolusso@rm.unicatt.it.
authors: Barbara
authors: B
authors: Tolusso
authors: Institute of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy. elisa.gremese@rm.unicatt.it.
authors: Elisa
authors: E
authors: Gremese
authors: Institute of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy. gf.ferraccioli@rm.unicatt.it.|Division of Rheumatology, Institute of Rheumatology and Affine Sciences, Complesso Integrato Columbus, Via Giuseppe Moscati, 31, 00168, Rome, Italy. gf.ferraccioli@rm.unicatt.it.
authors: Gianfranco
authors: G
authors: Ferraccioli
mesh_terms: D000068879:Adalimumab / Q000008:administration & dosage; D000328:Adult; D000368:Aged; D018501:Antirheumatic Agents / Q000008:administration & dosage*; D001172:Arthritis, Rheumatoid / Q000000981:diagnostic imaging* / Q000188:drug therapy*; D015331:Cohort Studies; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D000068800:Etanercept / Q000008:administration & dosage; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008727:Methotrexate / Q000008:administration & dosage; D008875:Middle Aged; D011446:Prospective Studies; D012008:Recurrence; D012074:Remission Induction; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*; D014463:Ultrasonography
chemical_list: D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha; D000068879:Adalimumab; D000068800:Etanercept; D008727:Methotrexate