Review Can we reduce the dosage of biologics in spondyloarthritis? Ignazio Olivieri a, ⁎, Salvatore D'Angelo a, b , Angela Padula a , Pietro Leccese a , Angelo Nigro a , Carlo Palazzi a a Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza and Matera, Italy b PhD Scholarship in Health Sciences, Department of Health Sciences, University of Molise, Campobasso, Italy abstract article info Article history: Accepted 15 August 2012 Available online 23 August 2012 Keywords: Ankylosing spondylitis Psoriatic arthritis TNF blockers TNF blockers have revolutionized the management of spondyloarthritis (SpA). To date, four anti-TNFα agents (etanercept, infliximab, adalimumab, golimumab) have been approved for the management of ankylosing spondylitis (AS) and psoriatic arthritis (PsA). The first objective in the management of AS and PsA with TNF inhibitors is to reduce disease activity to clinical remission or low disease activity. After remission has been achieved, this state should be maintained as long as possible. However, the financial burden associated with the cost of anti-TNF agents as well as concerns about their long-term safety suggest reducing the dosage of the drug or discontinuing the therapy in the hopes of drug-free remission. The aim of this review is to examine what has, till now, been published on this topic in axial SpA, which includes AS and non- radiographic axial SpA (nr-axSpA), peripheral SpA and PsA. Discontinuation of therapy in axial SpA is not possible in the majority of patients, while on the contrary, reducing the dosage often is. In some patients with peripheral SpA and PsA it is also possible to discontinue therapy and to achieve drug-free remission. © 2012 Elsevier B.V. All rights reserved. Contents 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691 2. Ankylosing spondylitis and non-radiographic axial spondyloarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692 3. Peripheral spondyloarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692 4. Psoriatic arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692 5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693 Take-home messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693 1. Introduction The spondyloarthritis (SpA) complex includes ankylosing spondylitis (AS), reactive arthritis (ReA), psoriatic arthritis (PsA), arthritis related to inflammatory bowel disease (IBD) and forms that do not fulfill established criteria for these definite categories which are labeled as undifferentiated SpA (uSpA) [1,2]. The management of SpA has been revolutionized by the introduction of tumor necrosis factor (TNF) blockers. So far, four anti-TNF agents (etanercept, infliximab, adalimumab, golimumab) have been approved for the management of AS and PsA on the basis of randomized controlled trials and observa- tional post-marketing studies showing consistent evidence supporting their safety and efficacy [3–11]. In both diseases, these drugs reduce signs and symptoms of inflammation and improve quality of life and functional status. In PsA, TNFα inhibitors decrease the progression rate of the structural damage in peripheral joints [7–10], while in AS there is no evidence of their ability to block the evolution of radiograph- ic damage to the spine [12–14]. Similar to rheumatoid arthritis (RA), the first objective in the man- agement of AS and PsA is to reduce disease activity to clinical remission or low disease activity. After remission has been achieved, this state should be maintained as long as possible. However, the financial burden associated with the cost of anti-TNF agents and concerns about their long-term safety maintains the desire to reduce the dosage or to discon- tinue therapy alive, trusting in drug-free remission. Some recent studies Autoimmunity Reviews 12 (2013) 691–693 ⁎ Corresponding author at: Rheumatology Department of Lucania, San Carlo Hospital, Contrada Macchia Romana, 85100 Potenza, Italy. Tel.: +39 0971 613039; fax: +39 0971 613036. E-mail addresses: ignazioolivieri@tiscalinet.it, i.olivieri@ospedalesancarlo.it (I. Olivieri). 1568-9972/$ – see front matter © 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.autrev.2012.08.013 Contents lists available at SciVerse ScienceDirect Autoimmunity Reviews journal homepage: www.elsevier.com/locate/autrev