Real-world treatment courses after anti-TNF de-escalation in older adults with rheumatoid arthritis: a medicare cohort study

Abstract Objective Older adults with rheumatoid arthritis (RA) treated with biologic disease-modifying antirheumatic drugs (bDMARDs), including anti-TNFs, are at an increased risk of adverse effects. Current guidelines recommend de-escalating DMARDs for patients with low disease activity or remission to optimize the benefit-harm ratio of treatment. Our prior study found that two-thirds of older adults with RA de-escalated anti-TNFs yet real-world treatment courses after de-escalation in older adults are poorly understood. We aimed to describe real-world post-de-escalation treatment courses and identify factors associated with re-escalation. Methods We used 20% Medicare data from 2009 to 2022 to identify RA patients ≥ 66 years of age on anti-TNF therapy with de-escalation by cessation (> 90-day gap) or by taper (> 50% effective dose reduction), and at least one rheumatologist visits pre- and post-de-escalation (i.e., index date). Re-escalation was defined as restarting the same anti-TNF or another bDMARD or increasing the effective dose by > 50% after de-escalation. Those without re-escalation were considered to have sustained de-escalation. Multivariable Cox proportional hazards regression models were used to identify factors associated with re-escalation, relative to sustained de-escalation. Results Among 949 beneficiaries who met inclusion criteria, the mean age was 75.1 years, 82.5% were female, and 41.9% had low-income subsidies (LIS). 38.4% sustained de-escalation, while 61.6% re-escalated treatment with a median time to re-escalation of 164 (IQR 113–301) days. In Cox analyses, re-escalation, compared to sustained de-escalation, was more likely among individuals who were Black, Hispanic/other, and with a lower comorbidity burden. Conclusions Nearly four in ten older adults with RA sustained de-escalation of anti-TNF, supporting the feasibility for selected individuals in routine practice. Most re-escalations occurred within six months, suggesting a need for closer follow-up early after de-escalation. Clinical trial number Not applicable.