Disease activity–guided dose optimization including discontinuation of TNF inhibitors in rheumatoid arthritis is effective for up to 10 years: an observational follow-up of the DRESS study

Objective The objective of this study was to investigate the safety and effectiveness of disease activity–guided dose optimization of TNF inhibitors in RA over 10 years. Methods The study involved an observational long-term extension of a randomized study of participants who completed the 3-year extension of the DRESS-study. After the randomized phase (months 0–18), disease activity–guided dose optimization was allowed for all. The main outcomes were mean time-weighted DAS28-CRP; biologic and targeted synthetic DMARD (b/tsDMARD) use per year, as proportion of daily defined dose; proportion of patients reaching discontinuation; durability and effectiveness of subsequent dose reduction attempts; and radiographic progression between years 3 and 10 using the Sharp–van der Heijde score. Results A total of 170 patients were included, of whom 127 completed the 10-year follow-up. The mean disease activity remained low (DAS28-CRP 2.13, 95% CI 2.10–2.16), while the b/tsDMARD dose reduced from 97% at baseline (95% CI 96–99%, n = 170) to 56% at year 10 (95% CI 49–63%, n = 127). Of 161 participants with an optimization attempt, 119 (74%) reached discontinuation with a median duration of 7 months (interquartile range 3–33 months), and 25 participants never had to restart their b/tsDMARD (21%, 95% CI 14–29%). The mean dose reduction after dose optimization was 48% (n = 159) for the first optimization attempt, and 33% for a subsequent attempt (n = 86). Of the 86 participants, 41 (48%) had radiographic progression exceeding the smallest detectable change (5.7 units), and progression was associated with disease activity, not b/tsDMARD use. Conclusion Long-term disease activity–guided dose optimization of TNF inhibitors in RA, including discontinuation and multiple tapering attempts, remains safe and effective.