Background While several registries have already evaluated the retention of first-line anti-TNF therapy in RA, divergent conclusions have at times been reported. Following treatment failure with a first-line anti-TNF agent, a non-TNF-targeted biologic is recommended rather than a second anti-TNF drug.
Objectives This study sought to compare the retention rate (RR) of a first-line anti-TNF treatment in routine care and in patients with inadequate or insufficient response the RR of either a second-line anti-TNF drug or a non-TNF-targeted biologic, in a monocenter cohort from Auvergne.
Methods All RA patients treated with anti-TNF between 2008 and 2015 were enrolled.
Results In total, 200 RA patients were analyzed, including 37 men and 163 women (81.5%). The mean age was 55.1 ± 13.1 years and disease duration was 8 years [3–15]. 89 (70.1%) patients had RF and 75 (72.8%) anti-CCP antibodies; 96 cases were erosive (69.6%). DAS-ESR was 4.87 ± 1.30. The first-line anti-TNF drugs were etanercept (ETA) (61%), adalimumab (ADA) (24%) or infliximab (IFM) (15%), either as monotherapy (14.6%) or associated with a DMARD (85.4%) (MTX: 64.5%). 131 patients had corticosteroids (mean dose: 7.5 mg/day). At 6 months, 73.8% were EULAR responders (27.8%: moderate; 46%: good). The overall median retention time (RT) was 55.1 months (ADA: 73.9 [19.3 -136.2], ETA 59.3 [17.1 –NA], IFM: 31.1 [7.1 -65.1] months). The RR of the first anti-TNF drug 2 years after initiation was 67.4% for ETA, 67.8% for ADA, and 55% for IFM. The hazard ratios (HR) for treatment cessation did not significantly differ between ETA and monoclonal antibodies. Inefficiencies were observed for 78 patients (70%), including 26 primary inefficiencies (33%) and 30% treatment discontinuations due to side-effects. Reasons for discontinuation did not significantly differ between the anti-TNF groups. IFM exhibited lower safety. Predictors of treatment discontinuation were older age, high activity disease, CRP, and rheumatoid nodules. In contrast, association with a DMARD significantly improved the median RT (17.5 vs. 60 months, 76 vs 29 months for MTX) for all anti-TNF drugs. Following treatment failure with the first anti-TNF therapy, a second anti-TNF was administered in 61 patients, while 44 were switched to a non-TNF-targeted biologic (22: rituximab; 8: abatacept; 10: tocilizumab; 4: anakinra). A second treatment failure was more common when using a second anti-TNF agent than with non-TNF-targeted biologics (77.1% vs. 9.1%, p<0.001). Loss of efficacy was the principal reason for discontinuing second anti-TNF drugs (46.8%). The median RT was 12 months [5–25] for second anti-TNF drugs and 10 months [6.5–14.5] for non-TNF-targeted agents. Treatment cessation did significantly differ between anti-TNF drugs and non-TNF-targeted agents (HR: 5.37 [51.92 -15.02]).
Conclusions Our results showed near-identical retention levels recorded for anti-TNF, lower safety for infliximab, improvement of retention when anti-TNF were associated with a DMARD and better efficacy achieved with a non-TNF-targeted biologic following the failure of a first-line anti-TNF treatment.
Disclosure of Interest None declared