Dose optimisation of TNF inhibitors results in considerable cost savings

TNF inhibitors are associated with long-term risks and high costs; improving how they are used is therefore important.


Rheumatoid arthritis is a chronic inflammatory disease that affects a person’s joints and sometimes their internal organs, causing pain and disability. It is more common in older people, and affects both men and women.
Adalimumab and etanercept are TNF inhibitors, a group of medicine known as biologic disease-modifying antirheumatic drugs (bDMARDs or biologics). These work by blocking the action of certain molecules involved in the development of inflammation in the body. Both have been used to treat rheumatoid arthritis for a long time. However, long-term treatment may be linked to an increased risk of infections or cancer, and can also be very expensive.


The authors hoped to find out whether a way of using a person’s disease activity to optimise the dose of etanercept or adalimumab could save money in people with rheumatoid arthritis.


The study included 180 people with rheumatoid arthritis at two clinics in the Netherlands. Everyone included had low disease activity and had been using either adalimumab or etanercept for at least 6 months.


This was an open-label, randomised controlled trial. People were assigned by chance to one of two treatment groups. Using chance in this way means that the groups will be similar and will allow the variable or treatment under investigation to be compared objectively. During the treatment both patients and their doctors knew which group they were in.
The first group were treated as normal. The second group received all normal care, but in addition they were given advice to increase the time between doses of their drug and then to stop taking it completely. This is sometimes also referred to as stepwise reduction, or tapering. The advice could be changed and the dose increased again if people’s disease flared or got worse.


After 18 months, the study found that 20% of people had been able to stop taking the drug completely, and 43% had been able to taper. The results were the same for people taking either adalimumab or etanercept. Overall, dose optimisation resulted in a saving of €12,280 per person, with no meaningful loss of quality of life.


To our knowledge, this is the first study reporting on the cost-effectiveness of a dose optimisation strategy for TNF inhibitors in people with rheumatoid arthritis.


A limitation of this analysis is the relatively short time, since people were studied for only 18 months. It is possible that there could be effects after this time. For example, the risks of non-melanoma skin cancer or serious infection might be lower in the dose optimisation group over a longer period. Another long-term effect that could influence the cost saving is the fact that some people in the optimisation group showed radiological progression (evidence of their disease getting worse when looked at on an X-ray). Although this was minimal, it was more than in the group who did not taper their medicine. This might mean that over a longer period of time the costs will rise. For example, if people need surgery or if they become disabled and cannot work. A long-term extension study is needed to answer these questions.


This information could form the basis for advice on how to implement an optimisation strategy based on disease activity in people with rheumatoid arthritis. Similar studies are being performed in people with psoriasis and Crohn’s disease.


If you have rheumatoid arthritis and are taking adalimumab or etanercept, you may be able to control your disease with lower or less frequent doses. This might help to save money, as well as protecting you from the risks of using biologic drugs for a long time.
It is very important that you do not reduce or taper your medicine yourself without taking medical advice. If you have any concerns about your disease or your medication, you should speak to your doctor.

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Date prepared: November 2016

Summary based on research article published on: 13 January 2016

From: Kievit, W. et al. Disease activity-guided dose optimisation of adalimumab and etanercept is a costeffective strategy compared with non-tapering tight control rheumatoid arthritis care: analyses of the DRESS study. Ann Rheum Dis 2016;0:1–6. doi:10.1136/annrheumdis-2015-208317

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