Background When a patient with rheumatoid arthritis (RA) fails initial treatment with a tumor necrosis factor inhibitor (TNFi) because of inadequate response or lack of tolerability, switching to another TNFi or to a non-TNFi is recommended, but this is based on limited evidence.1,2
Objectives This study examined real-world treatment patterns between patients with RA who switched from a TNFi to another TNFi (TNFi cyclers) compared with those who switched from a TNFi to a non-TNFi (non-TNFi switchers).
Methods The data source was an administrative claims database from a large managed care organization of commercial and Medicare Advantage patients in the United States. The “index claim” was the first TNFi (adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab) claim between January 2010 and February 2014 after ≥6 months of continuous enrollment pre-index. Eligible patients were aged ≥18 years at index with RA and no other autoimmune condition for which the study drugs could be used. The study included patients who subsequently switched either to another TNFi or to a non-TNFi (abatacept, tocilizumab, or tofacitinib) within 12 months post-index and had ≥12 months of additional follow-up. Each patient had 1 of 4 treatment patterns in the 12 months after the initial switch: (1) switched to a third TNFi or non-TNFi; (2) restarted the second therapy after a treatment gap of ≥45 days without switching; (3) discontinued the second therapy without switching or restarting; or (4) persisted with the second therapy without switching, restarting, or discontinuing. Adherence was defined as a proportion of days covered (PDC) of ≥80% for the second therapy.
Results Of 32,272 adult patients with RA who received ≥1 biologic, 1432 met all study criteria, including 379 non-TNFi switchers and 1053 TNFi cyclers. Most patients (81%) were female. Non-TNFi switchers were older (54.0 vs 51.1 y; P<0.001) and less likely than TNFi cyclers to be commercially insured (82% vs 90%; P<0.001). In the 12 months after the initial switch, non-TNFi switchers were significantly more likely than TNFi cyclers to persist on the second medication (51% vs 44%; P=0.021) and significantly less likely to switch to a third TNFi or non-TNFi (29% vs 37%; P=0.006); non-TNFi switchers and TNFi cyclers had similar rates of restarting therapy after a ≥45-day treatment gap (6% vs 8%; P=0.325) and discontinuation without restarting or switching therapy (14% vs 11%; P=0.185). In the 12 months after the initial switch, non-TNFi switchers were significantly more likely than TNFi cyclers to have high adherence (≥80% PDC) to the second medication (45% vs 38%; P=0.021).
Conclusions Among patients with RA, those who switched from a TNFi to a non-TNFi were more likely than TNFi cyclers to be persistent on the second medication in the first year, had greater adherence to the second medication, and were less likely to switch therapy again in the first year. The implications for clinical treatment outcomes deserve further study.
Singh et al. Arthritis Care Res (Hoboken). 2012;64:625–639.
Smolen et al. Ann Rheum Dis. 2014;73:492–509.
Acknowledgement This study was sponsored by Sanofi and Regeneron Pharmaceuticals, Inc. Jonathan Latham assisted with preparation and submission of the abstract.
Disclosure of Interest B. Chastek Employee of: Optum, which was hired by Sanofi and Regeneron Pharmaceuticals to conduct the research, J. Curtis Consultant for: Sanofi and Regeneron Pharmaceuticals, L. Becker Employee of: Optum, which was hired by Sanofi and Regeneron Pharmaceuticals to conduct the research, P. Mahajan Shareholder of: Sanofi, Employee of: Sanofi, C. Chen Shareholder of: Regeneron Pharmaceuticals, Inc., Employee of: Regeneron Pharmaceuticals, Inc.