Emery P, Breedveld FC, Hall S, et al. used standard Cochrane methodology. Main results One previously included Isocorynoxeine trial was excluded retrospectively in this update because it was not an RCT/CCT. We included eight additional trials, for a total of 14 studies (13 RCTs and one CCT, 3315 participants in total) reporting anti\TNF down\titration. Six studies (1148 participants) reported anti\TNF dose reduction compared with anti\TNF continuation. Eight studies (2111 participants) reported anti\TNF discontinuation compared with anti\TNF continuation (three studies assessed both anti\TNF discontinuation and dose reduction), and three studies assessed disease activityCguided anti\TNF dose tapering (365 participants). These studies included data on all anti\TNF brokers, Isocorynoxeine but primarily adalimumab and etanercept. Thirteen studies were available in full text, one was available as abstract. We assessed the included studies generally at low to moderate risk of bias; our main concerns were bias due to open\label treatment and unblinded outcome assessment. Clinical heterogeneity between the trials was high. The included studies were performed at clinical centres around the world and included people with early as well as established RA, the majority of whom were female with mean ages between 47 and 60. Study durations ranged from 6 months to 3.5 years. We found that anti\TNF dose reduction leads to little or no difference in mean disease activity score (DAS28) after 26 to 52 weeks (high\certainty evidence, mean difference (MD) 0.06, 95% confidence interval (CI) ?0.11 to 0.24, absolute risk difference (ARD) 1%) compared with continuation. Also, anti\TNF dose reduction does not result in an important deterioration in function after 26 to 52 weeks (Health Assessment Questionnaire Disability Index (HAQ\DI)) (high\certainty evidence, MD 0.09, 95% CI 0.00 to 0.19, ARD 3%). Next to this, anti\TNF dose reduction may slightly reduce the proportion of participants switched to another biologic (low\certainty evidence), but probably slightly increases the proportion of participants Isocorynoxeine with minimal radiographic progression after 52 weeks (moderate\certainty evidence, risk ratio (RR) 1.22, 95% CI 0.76 to 1 1.95, ARD 2% higher). Anti\TNF dose reduction may cause little or no difference in serious adverse events, withdrawals due to adverse events and proportion of participants with persistent remission (low\certainty evidence). Results show that anti\TNF discontinuation probably slightly increases the mean disease activity score (DAS28) after 28 to 52 weeks (moderate\certainty evidence, MD 0.96, 95% CI 0.67 to 1 1.25, ARD 14%), and that the RR of persistent remission lies between 0.16 and 0.77 (low\certainty evidence). Anti\TNF discontinuation increases the proportion participants with minimal radiographic progression after 52 weeks (high\certainty evidence, RR 1.69, 95% CI 1.10 to 2.59, ARD 7%) and may lead to a slight deterioration in function (HAQ\DI) (low\certainty evidence). It Rabbit Polyclonal to TAF15 is uncertain whether anti\TNF discontinuation influences the number of serious adverse events (due to very low\certainty evidence) and the number of withdrawals due to adverse events Isocorynoxeine after 28 to 52 weeks probably increases slightly (moderate\certainty evidence, RR 1.46, 95% CI 0.75 to 2.84, ARD 1% higher). Anti\TNF disease Isocorynoxeine activityCguided dose tapering may result in little or no difference in mean disease activity score (DAS28) after 72 to 78 weeks (low\certainty evidence). Furthermore, anti\TNF disease activityCguided dose tapering results in little or no difference in the proportion of participants with persistent remission after 18 months (high\certainty evidence, RR 0.89, 95% CI 0.75 to 1 1.06, ARD ?9%) and may result in little or no difference in switching to another biologic (low\certainty evidence). Anti\TNF disease activityCguided dose tapering may slightly increase proportion of participants with minimal radiographic progression (low\certainty evidence) and probably leads to a slight deterioration of function after 18 months (moderate\certainty evidence, MD 0.2 higher, 0.02 lower to 0.42 higher, ARD 7% higher), It is uncertain whether anti\TNF disease activity\guided dose tapering influences the number of serious adverse events due to very low\certainty evidence. Authors’ conclusions We found that fixed\dose reduction of anti\TNF, after at least.