Cycling Strategies for TNF Inhibitors in Spondyloarthritis

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Philip J. Mease, MD, and John D. Reveille, MD, discuss the strategies for TNF-inhibitor cycling in spondyloarthritis.

Philip J. Mease, MD: There is a strategy for TNF (tumor necrosis factor) cycling. Obviously, when a patient is losing response or hasn’t had a response to their initial anti-TNF medication, historically, we’ve moved on to a second anti-TNF medication. It turns out that if a patient has had a response to the initial TNF inhibitor but then lost response, they do pretty well with trying a second one and having a good response. If they’re never responding at all to their first anti-TNF try, then the second one may not work—but at least it’s worth a try.

We also have found, for example, in a study with certolizumab, one-fifth of the patients in that trial who had been on previous anti-TNF therapy, their response in that trial to that particular agent was as good as the patients who had not seen anti-TNF therapy before. So, this lends credence to the idea that there’s certainly rationale for cycling from one anti-TNF to another.

One of the reasons that we may do this is because there is good evidence for inhibition of structural damage. And so the idea that we would try to get the clinical response and maintain that inhibition of damage is an important goal. That reinforces the rationale for TNF cycling.

John D. Reveille, MD: Generally, patients do respond. Sometimes the anti-TNF agents either do not provide an adequate response or the patient has an adequate response and then subsequently breaks through. The American College of Rheumatology/SPARTAN (Spondyloarthritis Research and Treatment Network)/SAA (Spondylitis Association of America) Treatment Guidelines suggest if that does happen to the patient, you should make sure you can show that the pain is coming from the disease and not from some other issue—like a compression fracture of the spine or a fracture elsewhere—or more mechanical issues that may be cause for a knee wearing out or something, because obviously a biologic agent isn’t going to help that. Bu, if you show that it’s indeed inflammatory pain and the patient is having an inadequate response to one tumor necrosis factor inhibitor, then another should be tried. That is the official recommendation. So, you would then call cycling to another. I generally, as a rule, do not tend—in routine practice, if a patient is doing well on one TNF inhibitor—to switch them to another, to get off the sort of resistance building up. Usually, that is not going to be a major issue. And, in fact, I’ve seen adverse events occur from doing that.