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Stopping methotrexate, staying on etanercept provides best RA outcomes after remission

Publish date:: December 7, 2020

Key clinical point: Withdrawal of methotrexate leads to better outcomes than withdrawal of etanercept following a stringently determined disease remission.

Major finding: At week 48, 28.7% of the methotrexate-only group were in remission, compared with 49.5% of the etanercept-only group and 52.9% of patients on combined therapy.

Study details: A randomized, controlled trial in which 253 patients were assigned 2:2:1 to withdraw etanercept, withdraw methotrexate, or continue on both drugs.

Disclosures: The study was funded by Amgen. Dr. Curtis has received grants or research support from AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, and UCB. Dr. Pope consults for a variety of pharmaceutical companies.

Commentary

“Patients with RA are often treated with combination biologic and synthetic DMARDs. The burden of therapy, both in terms of cost and side effects, raises the question of the correct approach in patients whose RA is in sustained remission: can medications be stopped without detrimental effects on disease activity? This study, sponsored by Amgen, looked at 263 RA patients on combination therapy with methotrexate and etanercept in SDAI remission. Patients were randomized to discontinue either medication or remain on combination therapy; outcomes of disease remission was examined over 1 year.

At week 48, 50% of patients receiving etanercept monotherapy remained in SDAI remission compared to 29% of patients on methotrexate alone. Reassuringly, 70-80% of patients who worsened on monotherapy and were re-treated with combination etanercept and methotrexate then achieved remission within 12 weeks. Interestingly, only 53% of patients who remained on combination therapy also remained in remission, raising the question of whether these patients were indeed in sustained remission. Given this finding, it is unclear whether the study should be interpreted to support withdrawal of medication, though withdrawal of methotrexate seems to lead to less favorable outcomes.”