Abstract
According to international recommendations, the selection of the biologic disease modifying anti-rheumatic drug (bDMARD) for rheumatoid arthritis (RA) is mainly left to the clinician’s preference. We analyzed the real-life factors influencing the first-line choice or the switching strategy, focusing on the prescription of abatacept (ABA) or tocilizumab (TCZ) compared to TNFα inhibitors (TNFi). Patients enrolled in the Lombardy Rheumatology Network (LORHEN) Registry after January 1, 2010, when all considered bDMARD agents were available, were included. The population was divided into “first-” and “second-line” bDMARD. We included 1910 patients (first line n = 1264, second line n = 646). Age was higher in ABA or TCZ vs TNFi treated patients (p < 0.0001). Positive latent tuberculosis screening was associated with first-line ABA (p = 0.002). Methotrexate (MTX) combination therapy was lower in the TCZ group (p = 0.02). The type (dyslipidemia, hypertension, pulmonary disease) and the number of comorbidities influenced the choice towards ABA (p = 0.01). Multinomial logistic regression demonstrated that a second-line treatment, higher age, dyslipidemia, pulmonary disease, other comorbidities, and extra-articular RA manifestations were associated with ABA compared to TNFi. TCZ was associated with a second-line treatment, higher age, and more severe disease activity. Stopping the first bDMARD due to adverse events (AE) influenced the choice towards ABA. In real life, higher age and comorbidities influence the choice towards ABA and TCZ compared to TNFi. ABA was preferred in case of suspension of previous treatments due to AE. After failing a first-line TNFi, swapping to a different mechanism of action is more common.
Highlights
In the last decade, major advances have been brought to the management of rheumatoid arthritis (RA)
The aim of this study was to retrospectively analyze the factors influencing the choice of the first-line biologic disease modifying anti-rheumatic drug (bDMARD) or the switching strategy in a large cohort of real-life RA patients enrolled in the Italian Lombardy Rheumatology Network (LORHEN) Registry, focusing on the prescription of ABA or TCZ compared to TNFα inhibitors (TNFi)
Patients treated with a first-line bDMARD were 1264 (ABA first line: 115 patients; TCZ first line: 130; TNFi first line: 1019)
Summary
Major advances have been brought to the management of rheumatoid arthritis (RA). Biologic disease modifying anti-rheumatic drugs (bDMARDs) have become the standard of care for the treatment of RA not adequately responding to conventional synthetic DMARDs (csDMARDs). Several bDMARDs acting at different levels of the immune response have been licensed for the treatment of RA. TNFα inhibitors (TNFis) encompass five different agents: infliximab (IFX), including the recently approved infliximab bio-similar (bs-IFX); etanercept (ETA), adalimumab (ADA); golimumab (GOL); and certolizumab pegol (CZP) [1], allowing to choose among different routes and frequency of administration and peculiar. The introduction of the interleukin-6 (IL-6) receptor blocking monoclonal antibody tocilizumab (TCZ), the T-cell co-stimulation inhibitor abatacept (ABA), and the anti-CD20 B-cell depleting agent rituximab (RTX) have further increased the therapeutic armamentarium to treat RA. Despite the wide range and evolving spectrum of bDMARD options available, little is still known on the best approach to the individual patient, and the choice of the first line or sequencing bDMARDs is still largely left to the clinician’s choice and personal experience
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