Cochrane · systematic review · CD010455
Down‐titration and discontinuation strategies of tumour necrosis factor–blocking agents for rheumatoid arthritis in patients with low disease activity
Verhoef, LM, van den Bemt, BJF, van der Maas, A, et al. · Cochrane Database of Systematic Reviews · 2019 · Cochrane Library
SoF tableOnly the outcomes this review put in its Summary of Findings table are listed (the Cochrane Handbook caps them at about seven per comparison). Its other analyses are not shown here.
Questions
21
current version
GRADE rated
19
No studies
2
Included studies
NR
No studies 2 · 9.5%Ungraded 0 · 0%Very low 2 · 9.5%Low 9 · 42.9%Moderate 4 · 19%High 4 · 19%
Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.
Questions and results
Current version onlyAnti‐TNF dose reduction versus anti‐TNF continuation
Population: people with rheumatoid arthritis with low disease activity using a standard dose of anti‐TNF agents
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Disease activity score Anti‐TNF dose reduction vs anti‐TNF continuation | no estimate extracted | 2 studies · 501 participants | High |
Proportion of participants with persistent remission Anti‐TNF dose reduction vs anti‐TNF continuation | RR 1.01 [0.8, 1.28] | 2 studies · 612 participants | Low Downgraded: inconsistency |
Proportion of participants switched to another biologic Anti‐TNF dose reduction vs anti‐TNF continuation | RR 0.4 [0.17, 0.93] | 1 study · 323 participants | Low Downgraded: risk of bias |
Proportion of participants with minimal radiographic progression Anti‐TNF dose reduction vs anti‐TNF continuation | RR 1.22 [0.76, 1.95] | 2 studies · 553 participants | Moderate Downgraded: imprecision |
Function Anti‐TNF dose reduction vs anti‐TNF continuation | no estimate extracted | 2 studies · 501 participants | High |
Number of serious adverse events Anti‐TNF dose reduction vs anti‐TNF continuation | RR 1.09 [0.65, 1.82] | 5 studies · 1084 participants | Low Downgraded: risk of bias, imprecision |
Withdrawals due to adverse events Anti‐TNF dose reduction vs anti‐TNF continuation | RR 1.07 [0.51, 2.24] | 3 studies · 937 participants | Low Downgraded: risk of bias, imprecision |
Anti‐TNF discontinuation versus anti‐TNF continuation
Population: people with rheumatoid arthritis with low disease activity using a standard dose of anti‐TNF agents
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Disease activity score ‐ Anti‐TNF discontinuation vs anti‐TNF continuation | no estimate extracted | 2 studies · 733 participants | Moderate Downgraded: inconsistency |
Proportion of participants with persistent remission Anti‐TNF discontinuation vs anti‐TNF continuation | no estimate extracted | 6 studies · 1188 participants | Low Downgraded: inconsistency |
Proportion participants that switched to another biologic due to loss of response ‐ not measured Anti‐TNF discontinuation vs anti‐TNF continuation | no estimate extracted | NR | No studies |
Proportion participants with minimal radiographic progression Anti‐TNF discontinuation vs anti‐TNF continuation | RR 1.69 [1.1, 2.59] | 3 studies · 549 participants | High |
Function Anti‐TNF discontinuation vs anti‐TNF continuation | no estimate extracted | 4 studies · 1498 participants | Low Downgraded: inconsistency |
Number of serious adverse events Anti‐TNF discontinuation vs anti‐TNF continuation | RR 1.29 [0.82, 2.03] | 8 studies · 2095 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Withdrawals due to adverse events Anti‐TNF discontinuation vs anti‐TNF continuation | RR 1.46 [0.75, 2.84] | 4 studies · 1116 participants | Moderate Downgraded: imprecision |
Anti‐TNF disease activity–guided dose tapering versus anti‐TNF continuation
Population: people with rheumatoid arthritis with low disease activity using a standard dose of anti‐TNF agents
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Disease activity score Anti‐TNF disease activity–guided dose tapering vs anti‐TNF continuation | no estimate extracted | 3 studies · 357 participants | Low Downgraded: inconsistency |
Proportion of participants with persistent remission Anti‐TNF disease activity–guided dose tapering vs anti‐TNF continuation | RR 0.89 [0.75, 1.06] | 1 study · 180 participants | High |
Proportion of participants switched to another biologic due to loss of response Anti‐TNF disease activity–guided dose tapering vs anti‐TNF continuation | RR 0.62 [0.25, 1.54] | 2 studies · 317 participants | Low Downgraded: imprecision |
Proportion of participants with minimal radiographic progression Anti‐TNF disease activity–guided dose tapering vs anti‐TNF continuation | RR 1.45 [0.77, 2.73] | 2 studies · 312 participants | Low Downgraded: imprecision, inconsistency |
Function Anti‐TNF disease activity–guided dose tapering vs anti‐TNF continuation | no estimate extracted | 1 study · 123 participants | Moderate Downgraded: imprecision |
Number of serious adverse events Anti‐TNF disease activity–guided dose tapering vs anti‐TNF continuation | RR 1.24 [0.42, 3.7] | 2 studies · 317 participants | Very low Downgraded: imprecision, inconsistency |
Withdrawals due to adverse events ‐ not measured Anti‐TNF disease activity–guided dose tapering vs anti‐TNF continuation | no estimate extracted | NR | No studies |
Summary of findings on anti‐TNF dose reduction
Population: patients with rheumatoid arthritis with low disease activity using a standard dose of anti‐TNF agents
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Mean disease activity score Measured by DAS28 (scale from 0.9‐8; higher score shows worse disease activity) ( | no estimate extracted | 1 study · 404 participants | Moderate Downgraded: imprecision |
Proportion of participants with persistent low disease activity Measured by DAS28 ( | RR 0.87 | 3 studies · 557 participants | Low Downgraded: risk of bias, imprecision, indirectness |
Proportion of participants with persistent loss of response, refractory to reinstalment of tapered anti‐TNF ( | no estimate extracted | 1 study · 52 participants | Very low Downgraded: risk of bias, imprecision, indirectness |
Radiographic progression Measured by modified Sharp‐van der Heijde score (scale from 0‐448; higher score shows more radiographic joint damage) ( | no estimate extracted | 1 study · 368 participants | Moderate Downgraded: imprecision |
Function Measured by HAQ (scale from 0‐3; higher score is worse functioning) ( | no estimate extracted | 1 study · 404 participants | Moderate Downgraded: imprecision |
Number of serious adverse events ( | RR 0.58 | 1 study · 404 participants | Moderate Downgraded: imprecision |
Withdrawals due to adverse events ( | RR 0.57 | 1 study · 404 participants | Moderate Downgraded: imprecision |
Summary of findings on anti‐TNF discontinuation
Population: participants with rheumatoid arthritis with low disease activity using a standard dose of anti‐TNF agents
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Mean disease activity score Measured by DAS28 (scale from 0.9‐8; higher score shows worse disease activity) ( | no estimate extracted | 1 study · 402 participants | Moderate Downgraded: imprecision |
Proportion of participants with persistent low disease activity Measured by DAS28 ( | RR 0.43 | 5 studies · 728 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Proportion of participants with persistent loss of response, refractory to reinstalment of tapered anti‐TNF ( | no estimate extracted | 0 studies · 0 participants | Ungraded |
Radiographic progression Measured by modified Sharp‐van der Heijde score (scale from 0‐448; higher score shows more radiographic joint damage) ( | no estimate extracted | 1 study · 351 participants | Moderate Downgraded: imprecision |
Function Measured by HAQ (scale from 0‐3; higher score shows worse functioning) ( | no estimate extracted | 1 study · 402 participants | Moderate Downgraded: imprecision |
Number of serious adverse events ( | RR 1.26 | 1 study · 402 participants | Moderate Downgraded: imprecision |
Withdrawals due to adverse events ( | RR 0.72 | 1 study · 402 participants | Moderate Downgraded: imprecision |
Summary of findings on disease activity–guided anti‐TNF dose tapering
Population: participants with rheumatoid arthritis with low disease activity using a standard dose of anti‐TNF agents
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Mean disease activity score Measured by DAS28 (scale from 0.9‐8; higher score shows worse disease activity) ( | no estimate extracted | 1 study · 137 participants | Low Downgraded: risk of bias, imprecision |
Proportion of participants with persistent low disease activity Measured by DAS28 ( | no estimate extracted | 0 studies · 0 participants | Ungraded |
Proportion of participants with persistent loss of response, refractory to reinstalment of the tapered anti‐TNF ( | no estimate extracted | 0 studies · 0 participants | Ungraded |
Radiographic progression Measured by modified Sharp‐van der Heijde score (scale from 0‐448; higher score shows more radiographic joint damage) ( | no estimate extracted | 0 studies · 0 participants | Ungraded |
Function Measured by HAQ (scale from 0‐3; higher score shows worse functioning) ( | no estimate extracted | 1 study · 123 participants | Low Downgraded: risk of bias, imprecision |
Number of serious adverse events ( | no estimate extracted | 0 studies · 0 participants | Ungraded |
Withdrawals due to adverse events ( | no estimate extracted | 0 studies · 0 participants | Ungraded |