Non-inferiority of dose reduction versus standard dosing of TNF-inhibitors in axial spondyloarthritis

Arthritis Res Ther. 2019 Jan 8;21(1):11. doi: 10.1186/s13075-018-1772-z.


Objective: The objective was to determine if dose reduction is non-inferior to full-dose TNFi to maintain low disease activity (LDA) in patients already in remission with TNFi, in axial spondyloarthritis.

Methods: Randomized, parallel, non-inferiority, open-label multicentre clinical trial. Patients were eligible if they had axial spondyloarthritis and had been in clinical remission for ≥ 6 months with any available TNFi (adalimumab, etanercept, infliximab, golimumab) at the dose recommended by product labelling. Patients were randomized by automated central allocation to continue the same TNFi dose schedule, or to reduce the dose by roughly half according to the protocol. The main outcome was the proportion of subjects with LDA after 1 year. Serious adverse reactions or infections were recorded.

Results: The trial stopped due to end of the funding period, after 126 patients were randomized; 113 patients (84.1% male, mean age (SD) 45.6 (13.0) years) were included in the main per-protocol subset. Non-inferiority was concluded for LDA at 1 year (47/55 (83.8%) patients in the full-dose and 48/58 (81.3%) patients in the reduced-dose arm, adjusted difference (95% CI) - 2.5% (- 16.6% to 11.7%)). Serious adverse reactions or infections were reported in 7/62 patients (11.3%) assigned to full dose and 2/61 patients (3.3%) assigned to reduced dose (p value = 0.164).

Conclusion: In patients with ankylosing spondylitis in clinical remission for at least 6 months, dose reduction is non-inferior to full TNF inhibitor doses to maintain LDA after 1 year. Serious adverse events may be less frequent with reduced doses.

Trial registration: EU Clinical Trials Registry, EudraCT 2011-005871-18 and, NCT01604629 .

Keywords: Dose-tapering; Non-inferiority; Spondyloarthritis; TNF inhibitors.

Publication types

  • Comparative Study
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adalimumab / pharmacology
  • Adalimumab / therapeutic use
  • Adult
  • Antibodies, Monoclonal / pharmacology
  • Antibodies, Monoclonal / therapeutic use
  • Dose-Response Relationship, Drug
  • Etanercept / pharmacology
  • Etanercept / therapeutic use
  • Female
  • Humans
  • Infliximab / pharmacology
  • Infliximab / therapeutic use
  • Male
  • Middle Aged
  • Prospective Studies
  • Spondylarthritis / diagnosis*
  • Spondylarthritis / drug therapy*
  • Tumor Necrosis Factor Inhibitors / pharmacology
  • Tumor Necrosis Factor Inhibitors / therapeutic use*
  • Tumor Necrosis Factor-alpha / antagonists & inhibitors*


  • Antibodies, Monoclonal
  • Tumor Necrosis Factor Inhibitors
  • Tumor Necrosis Factor-alpha
  • golimumab
  • Infliximab
  • Adalimumab
  • Etanercept

Associated data

  • EudraCT/2011–005871-18