Long-term treatment of rheumatoid arthritis with tumour necrosis factor blockade: outcome of ceasing and restarting biologicals

Sir, Infliximab, a chimeric monoclonal antibody, has demonstrated effective suppression of disease and prevention of the progression of structural damage in rheumatoid arthritis (RA) in its phase III randomized study (ATTRACT study) [1, 2]. Two anti-tumour-necrosis factor α (TNF-α) drugs, infliximab and etanercept, have recently been approved by the National Institute of Clinical Excellence [3]. With a large number of patients at a single centre for the ATTRACT study [1], the follow-up of our patients represents a special cohort of patients with RA who have received 2 yr of TNF-α blockade. Consequently, several questions arose regarding their long-term management, the most important being whether they would flare when anti-TNF-α treatment ceased and, if so, did the maintenance of response depend on the previous dose and response? Finally, the practical question of whether the drug could be restarted safely and effectively was addressed. This is of particular relevance because of concerns regarding the development of human anti-chimeric antibodies when infliximab treatment is interrupted. This study provides new insights into the strategy of long-term therapy with infliximab. This observational study was in accordance with our local ethics committee guidelines.