We asked Scott J. Zashin, MD, the following questions:
- Can or should rheumatoid arthritis patients stop using TNF blockers if they achieve remission?
- How long should they be in remission before discontinuing treatment with a TNF blocker?
- If symptoms return, can the TNF blocker be re-started?
What Are TNF Blockers?
TNF blockers target TNF-alpha activity. TNF alpha is one of the most important cytokines involved in rheumatoid arthritis through its entanglement with inflammatory reactions. TNF blockers bind to TNF-alpha, render it inactive, and interfere with inflammatory activity, ultimately decreasing joint damage.
What Is a Remission?
A remission in rheumatoid arthritis is generally defined as the absence of clinical signs of inflammation. According to the American College of Rheumatology, remission involves the absence of symptoms such as joint pain, joint stiffness, joint tenderness.
Can Remission Be Achieved With TNF Blockers?
With the potential to interfere with inflammation and reduce joint damage, it seems TNF blockers may produce a remission in some patients. Is it possible for the fortunate patient, who achieves remission while using a TNF blocker, to stop using the drug?
Dr. Zashin explained "While up to 10% of patients diagnosed with rheumatoid arthritis may go into a sustained remission, the majority of patients have symptoms that persist and require regular treatment. The same is true for patients with ankylosing spondylitis. On the other hand, patients with psoriatic arthritis may experience long-term remissions." Dr. Zashin continued, "As a result, it is with these patients that I am typically more aggressive in stopping medication when appropriate. If the symptoms recur, then I will resume treatment. While it is possible that patients may not get the same benefit when resuming medications, most patients seem to respond just as well."
"Based on the patient's presentation (meaning, the patient's symptoms), the rheumatologist (arthritis specialist) prescribing a TNF blocker may elect to taper the dose. For example, those on Humira (adalimumab), may try taking the injection every 3 weeks, or Enbrel (etanercept) less frequently. In patients on Remicade (infliximab), stopping the drug can be a problem because patients taking Remicade develop what are called chimeric antibodies which are antibodies to the foreign, mouse protein. After being off drug for a prolonged period, they may develop a potentially serious infusion reaction when they resume treatment," according to Dr. Zashin.
Discuss your medication options or possible medication changes with your own doctor. In some cases, it may be more appropriate to taper or lower the dose of the drug rather than stop it.
Dr. Zashin is clinical assistant professor at University of Texas Southwestern Medical School and an attending physician at Presbyterian Hospitals of Dallas and Plano. Dr. Zashin is author of Arthritis Without Pain - The Miracle Of TNF Blockers. The book is useful for anyone on one of the biologic drugs or considering the biologic drugs.