Background The therapeutic armamentarium for the treatment of rheumatoid arthritis (RA) has been significantly implemented with the use of biologic-disease modifying anti-rheumatic drugs (bDMARDs). TNF inhibitors (TNFi), abatacept (ABA) or tocilizumab (TCZ) are all approved as first-line biologic agents. International Recommendations (1) do not provide a preference on the mechanism of action (MoA) to be chosen first or after the failure of bDMARD therapy.
Objectives To analyse the factors influencing the choice of the first-line bDMARD or the switching strategy in RA, focusing on the prescription of ABA or TCZ compared to TNFi.
Methods Patients were selected from the Lombardy Rheumatology Network (LORHEN) Registry. The analysis was limited to patients enrolled after 2008, when all three different MoA were available. The study population was divided into “first-line” and “second-line” bDMARD.
Results A total of 1910 patients were included. First line n=1264, second line n=646 patients. Both age at diagnosis and at bDMARD initiation were significantly lower in patients treated with first-line TNFi compared to ABA and TCZ (p<0.0001). A positive screening for latent tuberculosis was more represented in the group treated with first-line ABA compared to TCZ or TNFi (p=0.002). Combination therapy with methotrexate (MTX) was significantly lower in the TCZ group (50.77% of patients), compared to both ABA (86.70%) and TNFi (64.28%); p=0.02. The presence of dyslipidemia (p=0.018), hypertension (p=0.002) or concomitant pulmonary disease (p<0.0001) was significantly associated with the choice of ABA first-line. The presence of other comorbidities in general and of ≥2 comorbidities influenced the choice of the bDMARD towards ABA (p=0.01). When switching to a second line of treatment, patients with higher DAS28 were more frequently treated with TCZ compared to TNFi (p=0.005) or ABA (p=0.038). The presence of peripheral neuropathy also influenced the choice towards ABA Vs TNFi (p=0.005). TCZ, followed by ABA showed the lowest interruption rate compared to TNFi (p=0.002 and p=0.003, respectively). Multinomial logistic regression demonstrated that a second-line treatment, higher age, dyslipidemia, pulmonary disease, other comorbidities, and extra-articular RA manifestations such as vasculitis were all associated with the choice of ABA compared to TNFi. The choice of TCZ was associated with a second line of treatment, higher age and more severe disease activity.
Conclusions According to International Guidelines, the selection of the first and second-line bDMARD is left to the clinician's preference. However, real-life data suggest that higher age and comorbidities influence the choice towards ABA and TCZ compared to TNFi. After failing a first-line TNFi, a strategy of swapping to a different MoA is more common.
Smolen JS, Landewé R, Breedveld FC, Buch M, Burmester G, Dougados M, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis 2014;73(3):492–509.
Disclosure of Interest None declared