Background Despite the treatment successes of etanercept in most JIA patients, around 10-22% of previously biologically-naive JIA patients discontinued etanercept within 12 months because of a lack of effectiveness or intolerance. Tynjala et al. mainly described patients switching from etanercept to infliximab (and visa versa), but studies focusing on switching from etanercept to the remaining biological agents are lacking for JIA.
Objectives To evaluate the effectiveness and safety of switching to a second or third biological agent in juvenile idiopathic arthritis (JIA) after etanercept failure.
Methods The ABC register (observational prospective cohort) includes all Dutch JIA patients who use or previously used biological agents. Data on the disease course were used to estimate drug survival with Kaplan-Meier and calculate adverse event (AE)-rates.
Results Of 307 biologically-naïve JIA patients who started etanercept, 80 (26%) switched to a second, and 22 (7%) to a third biological. During 1,030 patient-years of follow-up after introduction of etanercept, 49 switches to adalimumab, 28 infliximab, 17 anakinra, 4 abatacept, and 4 trial drugs were evaluated. Eighty-four percent (95% CI, 80-88%) of patients who started etanercept as a first biological were, after 12 months, still on the drug, compared with 47% (95% CI, 35-60%) of patients who started a second, and 51% (95% CI, 26-76%) of patients who started a third biological agent. Patients who switched because of primary ineffectiveness seemed to continue the second agent less often (32% still on drug after 12 months, 95% CI 12%>53%). After etanercept failure, drug continuation of adalimumab was similar to infliximab for patients with non-systemic JIA-categories; anakinra was superior to a second TNF-blocker for systemic-JIA.(Figure 1) AE-rates within first 12 months after initiation were for each course and each biological comparable.
Conclusions In conclusion, switching between biological agents occurs frequently in daily practice and seems to be safe and, since limited options are available, justifiable for JIA patients who failed etanercept. After etanercept failure, adalimumab and infliximab were equally effective in JIA patients with non-systemic JIA categories, while anakinra was superior to a second TNF-alpha blocking agent in systemic JIA. The effectiveness of a second biological agent was lower than the first biological and seems especially low when the first agent was discontinued because of primary ineffectiveness.
Tynjala P, Vahasalo P, Honkanen V, Lahdenne P. Drug survival of the first and second course of anti-tumour necrosis factor agents in juvenile idiopathic arthritis. Ann Rheum Dis. 2009 Apr; 68(4):552-557.
Disclosure of Interest M. Otten: None Declared, F. Prince: None Declared, J. Anink: None Declared, R. Ten Cate: None Declared, E. Hoppenreijs: None Declared, W. Armbrust: None Declared, Y. Koopman-Keemink: None Declared, P. Van Pelt: None Declared, S. Kamphuis: None Declared, S. Gorter: None Declared, K. Dolman: None Declared, J. Swart: None Declared, J. Van den Berg: None Declared, N. Wulffraat: None Declared, M. Van Rossum: None Declared, L. Van Suijlekom-Smit Grant/Research support from: Dutch Board of Health Insurances, Pfizer International, Abbott, Consultant for: Pfizer International
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