Background In 2013 European League Against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA), tocilizumab (TCZ) has been added as a choice to biologic agents which are first used after inadequate response to methotrexate (MTX) treatment. When the treatment target has not been reached with an initial biological therapy, switching to other biological agents should be considered. It has been reported that after TNF inhibitor (TNFi) failure a biologic agent with different mode of action is better than altnernative TNFi. However, as for TCZ, there has been no report to compare clinical effectiveness and retention rates of alternative biologic agents switched from TCZ in patients with RA.
Objectives To analyse the effectiveness and retention rates of TNFi versus abatacept (ABT) in patients with RA following TCZ failure.
Methods All 372 patients with RA who underwent TCZ therapy in our institution from June 2008 to December 2013 were reviewed retrospectively. We focused on the patients in whom TCZ was switched to alternative biologic agent. Since rituximab is not allowed for RA in Japan, we divided those patients into two groups: switch to TNFi and to ABT. The changes of clinical parameters and disease activity were examined every 4 weeks from baseline to 24 weeks. The retention rates of those therapies at 24 weeks were also analyzed.
Results Of 372 patients treated with TCZ, a total of 49 patients were switched from TCZ to another biologic agent: 35 of TNFi (18 of infliximab,10 of etanercept, 4 of adalimumab, 3 of golimumab), and 14 of ABT. Reasons for switch from TCZ to those biologic agents were following: TNFi, lack of efficacy in 30 patients and safety in 5 patients; ABT, lack of efficacy in 12 patients and safety in 2 patients. When we picked up patients whose reason of switch was inefficacy, baseline characteristics including age, disease duration, and DAS28-CRP were not significantly different between TNFi and ABT groups except that concomitant MTX was higher in TNFi than in ABT (87% vs 17%, P<0.01). At 24 weeks, DAS28-CRP was significantly better in TNFi than in ABT (2.45 vs3.77, p=0.010, Fig. 1a). When CDAI was used to clear the strong effect on CRP reduction of TCZ, CDAI was also significantly better in TNFi than in ABT at 24 weeks (8.23 vs 15.74, P=0.049). HAQ score at week 24 was inclined to better inTNFi than in ABT, but it was not statistically significant (0.81 vs 1.20, p=0.201).The drug retention rates of TNFi was significantly better than that of ABT (86.7% and 58.3%, p=0.046; Fig. 1b).
Conclusions In patients with RA in whom TCZ was switched to alternative biologic agents due to lack of efficacy TNFi may be more effective than ABT.
Smolen JS, Landewé R, Breedveld FC, Buch M, Burmester G, Dougados M, Emery P, Gaujoux-Viala C, Gossec L, Nam J, Ramiro S, Winthrop K, de Wit M, Aletaha D, Betteridge N, Bijlsma JW, Boers M, Buttgereit F, Combe B, Cutolo M, Damjanov N, Hazes JM, Kouloumas M, Kvien TK, Mariette X, Pavelka K, van Riel PL, Rubbert-Roth A, Scholte-Voshaar M, Scott DL, Sokka-Isler T, Wong JB, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis. 2013 Oct 25. doi: 10
Disclosure of Interest None declared
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