Impact of dosing on treatment with TNF inhibitors: managing dose adjustment

The introduction of tumor necrosis factor (TNF) inhibitors for the treatment of rheumatoid arthritis (RA) represented a significant advance in the treatment of this debilitating disease, and led to dramatic changes in overall treatment goals and guidelines. Despite these advances, best practice use of TNF inhibitors in the clinical setting still needs to be determined. In particular, although all TNF inhibitors have standard, recommended doses that were determined in clinical trials, dose adjustments are often necessary in clinical practice to optimize therapeutic outcomes for individual patients. Dose escalation may be necessary in patients who experience disease flares, or because of insufficient initial efficacy or loss of efficacy over time, while dose tapering can be a response to adverse events, or if a patient achieves remission of disease. The amount of available evidence for managing dose adjustments for the currently available TNF inhibitors varies, and thus the strategies used with each are different. At present, although dose adjustments are common, data are insufficient for consensus guidelines to be recommended.