Can Patients With Controlled Rheumatoid Arthritis Taper Methotrexate From Targeted Therapy and Sustain Remission? A Systematic Review and Metaanalysis

Abstract

Objective To determine the risk of not being able to sustain remission after tapering MTX from targeted therapy in patients with controlled RA. Methods A systematic literature search was conducted in Medline, Embase and Cochrane Library for studies reporting remission outcomes after tapering MTX from targeted therapies in RA. Full-text articles and abstracts reported in English were included. Meta-analyses were conducted using random effects models. Forest and funnel plots were created. Results Ten articles were included. Studies evaluated MTX being tapered from combination treatment with TNF-inhibitors, tocilizumab, abatacept and tofacitinib. Nine studies were randomized and one was observational. Three out of 10 studies focused on early RA (<1 year). The MTX tapering strategy was gradual in 2 and rapid in 8 studies. Follow-up ranged from 3-18 months in randomized trials, and up to 3 years in the observational study. Our meta-analysis conducted in 2000 RA participants from 10 studies showed that patients who tapered MTX from targeted therapy had a 10% reduction in ability to sustain remission, an overall pooled RR 0.90 (95% CI 0.84, 0.97). There was no heterogeneity, (I2=0.0%, p=0.938). Our funnel plot indicated minimal publication bias. Conclusion Patients with controlled RA may taper MTX from targeted therapy with a 10% reduction in ability to sustain remission, for up to 18 months. Longer follow-up studies with attention to radiographic, functional and patient-reported outcomes are needed. The risk of disease worsening should be discussed with the patient with careful follow-up and prompt retreatment of disease worsening.