Disease Activity-Guided Dosing Safe, Effective for up to 10 Years in Rheumatoid Arthritis

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Noortje van Herwaarden, MD, PhD, discusses the results of a 10-year follow-up from the DRESS study and how it informs use of disease activity-guided dose optimization in treatment of rheumatoid arthritis.

New research presented at the European Congress of Rheumatology (EULAR) 2023 annual meeting provides insight into the 10-year effectiveness of disease activity-guided drug optimization in patients with rheumatoid arthritis.

An observational follow-up of patients who completed the Dose Reduction Strategy of Subcutaneous TNFi (DRESS) study, results of the analysis, which included data from 170 of the original 180, suggest disease activity-guided drug optimization of TNF inhibitors, including full discontinuation, for up to 10 years.1

A 3-year study evaluating disease activity-guided dose optimization, the DRESS study was published in 2017 and provided an overview of the safety and efficacy of disease activity-guided TNF inhibitor dose reduction in rheumatoid arthritis, with results indicating the benefits of treatment were maintained for up to 3 years, even with a large reduction in TNF inhibitor use, but no other benefits were observed.2

Citing an interest in the long-term safety and efficacy of disease activity-guided dose optimization, Noortje van Herwaarden, MD, PhD, of the Radboud University Medical Center, and a team of investigators designed the current study as an analysis of 10-year effectiveness among patients from with the DRESS study. With this in mind, the investigators’ analyses had 4 specific aims: assess disease activity over time, determine biological and targeted synthetic disease-modifying anti-rheumatic drug (b/tsDMARD) dose over time, estimate the proportion of patients with a DAGDO attempt, and estimate the proportion of patients with a discontinuation attempt and duration of b/tsDMARD discontinuation.1

As part of DRESS protocol, patients who completed the 3-year DRESS extension were followed observationally for up to 10 years. In the study, disease activity-guided dose optimization was defined as: 100% to 66% to 50% to 33% to 0% (full discontinuation), with each percentage representing a portion of the current daily dose.1

Among the 170 patients included in the current study, the median follow-up time was 10.0 (IQR, 9.3-10.3) years and the mean time-weighted DAS28-CRP during the entire follow-up period was 2.13 (95% confidence interval [CI], 2.10-2.16). Upon analysis, results suggested the TNF inhibitor dose decreased from 97% (95% CI, 96-99) at baseline to 49% (95% CI, 42-56) at year 5 and remained stable through end of follow-up.1

Further analysis of 161 patients with at least 1 disease activity-guided dose optimization suggested 74% (95% CI, 66-80) tapered until full discontinuation. Among those achieving full discontinuation, the median time from discontinuation to restart of the first discontinuation attempt was 8 (IQR 3-45) months. Investigators also pointed out 25 patients never had to restart their TNF inhibitor or another b/tsDMARD during the study.1

With an interest in learning more about how these results might help inform care, our editorial team sat down van Herwaarden during their time on-site at EULAR 2023.

Dr. van Herwaarden has no relevant disclosures to report.


  1. Van der Togt C, Den Broader N, Van der Maas A, Den Broeder A, Van Herwaarden N. DISEASE ACTIVITY-GUIDED DOSE OPTIMIZATION INCLUDING DISCONTINUATION OF TNF-INHIBITORS IN RHEUMATOID ARTHRITIS IS EFFECTIVE FOR UP TO 10 YEARS: RESULTS OF THE DRESS STUDY. Paper presented at: European Congress of Rheumatology (EULAR) 2023. Milan, Italy. May 31 – June 3, 2023.
  2. Bouman CA, van Herwaarden N, van den Hoogen FH, et al. Long-term outcomes after disease activity-guided dose reduction of TNF inhibition in rheumatoid arthritis: 3-year data of the DRESS study - a randomised controlled pragmatic non-inferiority strategy trial. Ann Rheum Dis. 2017;76(10):1716-1722. doi:10.1136/annrheumdis-2017-211169