When Is it Safe to Withdraw Infliximab in a Patient Receiving Combination Therapy With Methotrexate?

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When Is it Safe to Withdraw Infliximab in a Patient Receiving Combination

Therapy With Methotrexate?

http://www.medscape.com/viewarticle/523788?src=mp

Question

I have a 25-year-old female patient with juvenile rheumatoid arthritis. For

the past 10 years she has been treated with methotrexate (MTX); 4 years ago

infliximab was added to her treatment. If she has remained stable with no

new joint erosion and normal erythrocyte sedimentation rate (ESR) and

C-reactive protein (CRP), is it safe to withdraw infliximab and maintain her

on MTX? Exactly how long can we maintain the patient on a tumor necrosis

factor (TNF) inhibitor?

Ann Domingo, MD

Response from Arthur Kavanaugh, MD

University of California at San Diego, Division of Rheumatology, Allergy,

and Immunology, La Jolla, California.

This is an important question which research studies are now beginning to

address. If anti-TNF therapy could be withdrawn, this would have

pharmacoeconomic benefits as well as potential safety considerations. Such a

treatment regimen bears resemblance to the " induction-consolidation " type of

approach used in cancer studies.

The study that comes closest to providing an answer to this is the BeSt

study.[1] In this trial, patients with early rheumatoid arthritis were

randomized to 1 of 4 treatment arms. If patients were not under good

control, treatment had to be modified according to predefined algorithms. If

patients did very well for several consecutive months, treatment could be

tapered off. One of the treatment groups received MTX in combination with a

TNF inhibitor (infliximab). At 2 years, about 50% of the patients in this

group successfully discontinued their TNF inhibitor while maintaining

excellent clinical responses. Follow-up of these patients is continuing, and

of course among the most critical issues is how long benefit will be

maintained. At 2 years, the mean length of time for patients requiring no

TNF inhibitor was about 12 months. Further data are eagerly awaited.