Background Although much research has been done into factors influencing selection of biological therapies, there is a paucity of real-world data on the choices made by clinicians and the treatment pathways that patients undergo.
Methods We took patients booked into biological therapy clinics for adults with inflammatory arthritis over a 2-week period, excluding patients who had not yet received biologics. Digital medical records from the time of diagnosis were used to assess baseline characteristics and treatment pathways.
Results The records of 107 patients were reviewed. Mean age was 47.3±15.9 years, of which 52.3% were females (mean age 48.5±16.6) and 47.7% male (mean age 46.2±15.2). 41.1% had rheumatoid arthritis, 25.2% psoriatic arthritis, 21.5% ankylosing spondylitis, whilst the rest had other conditions. 5.6% were currently on DMARD therapy alone for different clinical reasons and 40.2% were on biologic + DMARD combined therapy. 54.2% were on biologic monotherapy, of which 46.6% were on Adalimumab, 32.8% Etanercept, 5.2% Tocilizumab, 5.2% Abatacept, 6.8% Infliximab, 1.7% Golimumab and 1.7% Rituximab. The majority (82.3%) of patients were started on anti TNF treatment as first biologic - Adalimumab (58.9%) or Etanercept (23.4%). A minority (17.7%) were started on Infliximab, Rituximab, Tocilizumab, Golimumab, Abatacept, Cimzia or experimental biologics. 62.6% of all patients were still on the first biologic prescribed at the time of the audit with a median treatment duration of 26 (±4.81) months. 61.9% of those prescribed Adalimumab as first-line were currently on the drug compared to 80.0% of those prescribed Etanercept as first-line, with median treatment durations of 15 (±4.93) months and 83.5 (±8.17) months, respectively. A smaller proportion of patients (36.4%) received multiple biologic therapies. Anti-TNF was the most popular second biologic choice - Etanercept (64.1%) and Adalimumab (17.9%). For patients on their third or more biologic, the choice was more varied, with most receiving Tocilizumab (29.4%), Rituximab (14.7%), Abatercept (17.6%) or Infliximab (14.7%). Inefficacy, either primary or secondary, was the most commonly cited reason for discontinuing or changing a treatment, comprising 60% of noted reasons.
Conclusions The results of this audit provide an insight into the treatment pathways NHS patients with inflammatory arthritis might expect. This real life data can inform practice and complement clinical trials regarding efficacy, giving clinicians the opportunity to inform patients about our own experience with using these therapies. The results suggest that anti-TNF therapy is still the first choice. Although current NICE guidelines recommend the use of concomitant DMARD therapy for most patients when a biologic is prescribed, our results showed that the majority of patients are treated with biological monotherapy, usually due to side-effects or good disease control with monotherapy. Although only Tocilizumab, Cimzia and Etanercept are licensed for monotherapy, Adalimumab, Abatacept, Golimumab and Rituximab are also used as monotherapy.
Disclosure of Interest None declared