Potential Optimalisation of (Expediency) and Effectiveness of TNF-blockers.

Background:

For the treatment of rheumatoid arthritis (RA) TNF blocking medication is very effective. TNF blocking medication, however, are relatively very expensive (1000 euro per month). Considering the chronic nature of RA patients are almost always treated by TNF blocking therapy for a long period of time. This longterm ( ‘lifelong’) treatment entails two problems: longterm safety and high costs for the Dutch healthcare system.



Goal:

The primary goal of this study is to determine whether it is possible to discontinue treatment with TNF blocking therapy in patients suffering from RA when the patient has had stable low disease activity.



Study Design:

The study design is an open label randomised controlled study design where patients are randomised to “discontinue TNF blocking therapy” or continue all anti-rheumatic medication including the TNF blocking therapy. After having signed informed consent, patients with rheumatoid arthritis (RA) who are being treated with TNF blocking medication, are randomised to:

1. Discontinue the TNF blocking therapy and continuing all other anti-rheumatic medication or;

2. Continuing all anti-rheumatic medication including the TNF blocker.



Primary outcome:

The primary outcome measure is the percentage of patients who experience an exacerbation of RA during the first year. Exacerbation is defined as a Disease Activity Score of 28 joint (DAS28) above3.2. with a DAS28 increase of above 0.6.



Patients’ burden:

Except for the randomisation, no interference with the current care of patients with RA take place. Patients with RA will be seen by a rheumatologist and a nurse once every 3 months, as the CBO guideline advises. All measurements which are part of standard care will be performed every 3 months. Patients will be followed for a maximum of 2 years (end of study period). During each visit to the outpatient clinic blood will be drawn for the determination of inflammation parameters, which is also a part of standard care of RA-patients in the Netherlands.



Patients' risk:

The discontinuation of TNF blocking therapy entails the risk that disease activity may rise. However, the study design guarantees that at an exacerbation of disease activity (DAS28>3.2) PLUS Delta Das28>0.6) the same TNF-blocker can be restarted. If this happens in the control group the patient may switch to another treatment with a biological, as is also customary in usual care. The patients will be monitored frequently, by measuring the disease activity by means of the DAS28 so that in case of an exacerbation treatment can be adjusted swiftly. The risk of unnecessarily continuing TNF blocking therapy is an increased risk of malignities and infections.

The primary goal of this study is to determine whether it is possible to discontinue treatment with TNF blocking therapy in patients suffering from Rheumatoid Arthritis when the patient has had stable low disease activity.

Interim reports every 3 months. Half way during the study and after the study intermediate and end report.

666 patients stop their TNF blocking therapy, the other 333 continue.