Discontinuation of infliximab and potential predictors of persistent low disease activity in patients with early rheumatoid arthritis and disease activity score-steered therapy: subanalysis of the BeSt study

Objective To describe the disease course after the cessation of infliximab in early rheumatoid arthritis patients with disease activity score (DAS)-steered treatment and to identify predictors of persistent low disease activity. Methods In a post-hoc analysis of the BeSt study, disease activity and joint damage progression were observed in patients treated with methotrexate plus infliximab, who discontinued infliximab after achieving low disease activity (DAS = 2.4) for 6 months. Predictors were identified using Cox regression analysis. Results 104 patients discontinued infl iximab, of whom 77 had received infl iximab plus methotrexate as initial treatment. Mean DAS at the time of infl iximab cessation was 1.3, median symptom duration was 23 months and median Sharp/van derHeijde score was 5.5. The median follow-up was 7.2 years. Infliximab was re-introduced after loss of low disease activity in 48%, after a median of 17 months. The joint damage progression rate did not increase in the year after cessation, regardless of flare. After re-introduction of infl iximab, 84% of these patients again achieved a DAS = 2.4. In the multivariable model, smoking, infl iximab treatment duration = 18 months and shared epitope (SE) were independently associated with the re-introduction of infl iximab: 6% of the non-smoking, SE-negative patients treated < 18 months needed infl iximab re-introduction. Conclusion Cessation of infl iximab was successful in 52%, with numerically higher success rates in patients initially treated with infl iximab. Of the 48% who flared, 84% regained low disease activity. The joint damage progression rate did not increase in the year after cessation. Smoking, long infl iximab treatment duration and SE were independently associated with re-introduction of infl iximab.