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Which subgroup of patients with rheumatoid arthritis benefits from switching to rituximab versus alternative anti-tumour necrosis factor (TNF) agents after previous failure of an anti-TNF agent?
  1. A Finckh1,
  2. A Ciurea2,
  3. L Brulhart1,
  4. B Möller3,
  5. U A Walker4,
  6. D Courvoisier5,
  7. D Kyburz2,
  8. J Dudler6,
  9. C Gabay1,
  10. on the behalf of the doctors of the Swiss Clinical Quality Management Programme for Rheumatoid Arthritis
  1. 1Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland
  2. 2Department of Rheumatology, University Hospital of Zurich, Zurich, Switzerland
  3. 3Department of Rheumatology, Clinical Immunology and Allergy, University Hospital of Bern, Bern, Switzerland
  4. 4Division of Rheumatology, University Hospital of Basel, Basel, Switzerland
  5. 5Division of Clinical Epidemiology, University Hospital of Geneva, Geneva, Switzerland
  6. 6Division of Rheumatology, University Hospital of Lausanne, Lausanne, Switzerland
  1. Correspondence to Dr A Finckh, Division of Rheumatology, Department of Internal Medicine, University Hospital of Geneva, 26 Av Beau-Sejour, 1211 Geneva 14, Switzerland; axel.finckh{at}hcuge.ch

Abstract

Background: Patients with rheumatoid arthritis (RA) with an inadequate response to TNF antagonists (aTNFs) may switch to an alternative aTNF or start treatment from a different class of drugs, such as rituximab (RTX). It remains unclear in which clinical settings these therapeutic strategies offer most benefit.

Objective: To analyse the effectiveness of RTX versus alternative aTNFs on RA disease activity in different subgroups of patients.

Methods: A prospective cohort study of patients with RA who discontinued at least one aTNF and subsequently received either RTX or an alternative aTNF, nested within the Swiss RA registry (SCQM-RA) was carried out. The primary outcome, longitudinal improvement in 28-joint count Disease Activity Score (DAS28), was analysed using multivariate regression models for longitudinal data and adjusted for potential confounders.

Results: Of the 318 patients with RA included; 155 received RTX and 163 received an alternative aTNF. The relative benefit of RTX varied with the type of prior aTNF failure: when the motive for switching was ineffectiveness to previous aTNFs, the longitudinal improvement in DAS28 was significantly better with RTX than with an alternative aTNF (p = 0.03; at 6 months, −1.34 (95% CI −1.54 to −1.15) vs −0.93 (95% CI −1.28 to −0.59), respectively). When the motive for switching was other causes, the longitudinal improvement in DAS28 was similar for RTX and alternative aTNFs (p = 0.40). These results were not significantly modified by the number of previous aTNF failures, the type of aTNF switches, or the presence of co-treatment with a disease-modifying antirheumatic drug.

Conclusion: This observational study suggests that in patients with RA who have stopped a previous aTNF treatment because of ineffectiveness changing to RTX is more effective than switching to an alternative aTNF.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Footnotes

  • ▸ An additional appendix is published online only at http://ard.bmj.com/content/vol69/issue2

  • Funding AF is supported by a research grant from the Geneva University and the Swiss National Science Foundation (grant No 3200B0-120639). CG is supported by the Swiss National Science Foundation (grant No 320000-119728). DC was partially supported by an unrestricted research grant from Hoffmann-La Roche Ltd for this project.

  • Competing interests SCQM has received grants from the Swiss Health authorities (BAG), the Swiss Academy for Medical Sciences (SAMW), the JL Warnery Foundation, the Swiss Society of polyarthritic patients (SPV) and pharmaceutical companies (Abbott, Essex, Wyeth, Roche, Bristol-Myers Squibb, Mepha, Novartis, Sanofi-Aventis).

  • Ethics approval Approved by the ethical committee of the Swiss Academy of Medical Sciences.

  • Provenance and Peer review Not commissioned; externally peer reviewed.

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