Background In patients with early rheumatoid arthritis (RA), aggressive treatment of disease activity with non-biologic disease modifying anti-rheumatic drugs (nbDMARDs) and biologics is recommended in order to reduce the long-term consequence of inflammation (1). We sought to estimate time from use of first nbDMARD to first biologic initiation in RA patients, as well as investigate factors associated with biologic initiation.
Methods We identified early RA patients (disease duration <1 year) within a national disease-based registry (CORRONA) with visits between 1/1/06 to 10/1/12. Survival analyses were performed using Kaplan-Meier curves estimating time from nbDMARD initiation to first biologic initiation. Median times to first biologic initiation were calculated. Cox proportional hazards models examined factors at nbDMARD initiation associated with time to biologic initiation including age, gender, baseline disease activity based on the clinical disease activity index [CDAI], insurance, disability (using the modified Health Assessment Questionnaire [mHAQ]) and prior nbDMARD use. We adjusted for clustering of patients by physician using the sandwich estimator for variance.
Results There were 2403 nbDMARD initiators who met inclusion criteria. Most were female (71.5%) with a mean age of 56.1 yrs, mean mHAQ of 0.5 and mean CDAI 19.9 with 73.8% having moderate or high disease activity (CDAI >10) at nbDMARD initiation. The median time between first nbDMARD and first biologic was 4.24 years.In univariate analyses, factors associated with time to biologic initiation include patient age (HR 0.98, 95% CI 0.97-0.99), private insurance (HR 1.50, 95% CI 1.18-1.90), moderate/high disease activity with low disease activity the reference (HR 2.01, 95% CI 1.27-3.17), greater disability (mHAQ; HR 1.47, 95% CI 1.08-2.00) and year of enrollment/diagnosis (HR 1.23, 95% CI 1.12-1.3). In multivariable models, only moderate/high disease activity (HR 1.02, 95% CI 1.01-1.04) and patient age (HR 0.98, 95% CI 0.98-0.99) were associated with time to biologic.
Conclusions In this real world cohort of RA patients, biologic therapy was started on average 4 ¼ years after initiation of a nbDMARD. Higher disease activity and younger patient age were associated with a reduced time to biologic initiation.
Singh JA, Furst DE, Bharat A, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis care & research. May 2012;64(5):625-639.
Acknowledgements The CORRONA RA registry has been supported through contracted subscriptions in the last two years by Abbvie, Amgen, AstraZeneca, Genentech, Horizon Pharma, Eli Lilly, Novartis, Pfizer, Vertex and UCB. The design, study conduct, and financial support for the study was provided by AbbVie. AbbVie participated in the interpretation of data, review, and approval of the abstract.
Disclosure of Interest : L. Harrold Grant/research support: CORRONA, J. Greenberg Shareholder of: CORRONA, Consultant for: AstraZeneca, Pfizer, Employee of: CORRONA, Y. Bao Shareholder of: AbbVie, Employee of: AbbVie, S. Grant Employee of: Statistical Center for HIV/AIDS Research & Prevention at Fred Hutchinson Cancer Research Center, J. Kremer Shareholder of: CORRONA, Employee of: CORRONA, G. Reed Employee of: CORRONA, S. Florentinus Shareholder of: AbbVie, Employee of: AbbVie, C. Karki Employee of: CORRONA, A. P. Lacerda Shareholder of: AbbVie, Employee of: AbbVie, A. Ganguli Shareholder of: AbbVie, Employee of: AbbVie