The influence of symptom duration on flare risk after biologic DMARD withdrawal in axial spondyloarthritis: a meta-analysis of randomized withdrawal trials

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• Picked for Rheumatology (top studies of the week, 26 July 2026): Meta‑analysis of flare risk after biologic withdrawal in axial spondyloarthritis

Abstract

OBJECTIVES: To assess whether symptom duration modifies flare risk after biologic/targeted synthetic DMARD (b/ts DMARDs) withdrawal in axial spondyloarthritis (axSpA) following remission/inactive disease. METHODS: We systematically identified randomized placebo-controlled trials evaluating withdrawal or tapering of b/tsDMARDs in axSpA through a previous systematic literature review. Eligible studies included adults with axSpA who achieved inactive disease or remission by ASDAS and were randomized to continuation or withdrawal/tapering, with available flare data. Patient-level data were obtained from Vivli and stratified by symptom duration thresholds of ≤2, 3, 4, or 5 years. Relative risks (RRs) of flare for continuation versus withdrawal were calculated within each subgroup, and relative risk ratios (RRRs) were estimated. Random-effects meta-analysis was performed. A subgroup analysis included only patients with nr-axSpA. RESULTS: Three RCTs involving 773 patients were included, evaluating adalimumab, certolizumab pegol, and ixekizumab versus placebo; no tsDMARD or tapering studies were eligible. Continuation of bDMARDs was consistently associated with fewer flares than withdrawal. Symptom duration did not significantly modify flare risk overall. In the overall axSpA population, pooled RRRs showed no statistically significant effect modification: 0.61 (95% CI 0.29-1.28) for ≤2 years, 0.77 (0.54-1.12) for ≤3 years, 0.83 (0.45-1.54) for ≤4 years and 0.82 (0.49-1.37) for ≤5 years. In nr-axSpA (n=508), pooled RRRs favoured shorter symptom duration at ≤4 years (0.25 (0.07-0.96)) but not at ≤2, ≤3 or ≤5 years. CONCLUSION: Symptom duration did not consistently modify flare risk after bDMARD withdrawal in axSpA overall, although exploratory findings suggest a potential effect in early nr-axSpA.

Abstract as published, via PubMed.