Abstract
BackgroundWith advancement in the treatment options of rheumatoid arthritis (RA), optimising the outcomes of difficult-to-treat patients has become increasingly important in clinical practice. In particular, insensitivity to first-line biologic disease-modifying anti-rheumatic drugs (bDMARD) is becoming a significant problem because it may decrease the treatment adherence of patients. This study aimed to compare RA patients with an insensitivity and those with a poor response to initial treatment with tumour necrosis factor inhibitors (TNFis), which are the most frequently used bDMARDs.MethodsThis is a retrospective cohort study using clinical data from the FIRST registry. bDMARD-naïve RA patients treated with tumour necrosis factor inhibitors (TNFis) from August 2003 to May 2019 were included and categorised into three groups: TNFi insensitivity, poor response to TNFis and controls. TNFi insensitivity was defined as follows: (1) discontinuation of TNFi treatment within 22 weeks due to lack of any response, or (2) an increase in the disease activity score in 28 joints–C-reactive protein (DAS28-CRP) of > 0.6 at week 22 compared with week 0. Among the remaining patients, those with a DAS28-CRP > 2.6 at week 22 were categorised in the poor response group.ResultsOf the included patients, 94 were classified in the insensitivity, 604 in the poor response and 915 in the control. A higher DAS28-CRP before treatment was a risk factor for a poor response but not for insensitivity. In contrast, dose escalation of infliximab decreased the risk of a poor response but not that of insensitivity.ConclusionsIn future research, poor and insensitivity to bDMARDs should be assessed separately to fully elucidate the aetiology of, and risk factors for, bDMARD refractoriness.
Highlights
With advancement in the treatment options of rheumatoid arthritis (RA), optimising the outcomes of difficult-to-treat patients has become increasingly important in clinical practice
The development of biologic disease-modifying antirheumatic drugs has dramatically expanded the therapeutic options for patients with rheumatoid arthritis (RA) who are refractory to conventional synthetic DMARDs
Global evidence indicates that when RA patients are refractory to Conventional synthetic DMARD (csDMARD), additive biologic disease-modifying anti-rheumatic drugs (bDMARD) treatment leads to clinical remission
Summary
With advancement in the treatment options of rheumatoid arthritis (RA), optimising the outcomes of difficult-to-treat patients has become increasingly important in clinical practice. Ochi et al Arthritis Research & Therapy (2020) 22:41 refractory status of RA can be roughly categorised into three groups: insensitivity, in which no improvement is observed from the start of treatment; secondary refractory, in which partial, but insufficient, improvement is evident; and false refractory, in which patients complain persistent pain though inflammation is absent [9]. Among these three conditions, identifying insensitivity to bDMARDs has significant clinical importance, because these patients experience no improvement in their symptoms by treatment, incurring unnecessary costs and toxicity [10].
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