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Abstract
Background Rheumatoid arthritis(RA) is frequently complicated by other comorbid diseases that may drivetherapeutic strategy or interfere with achieving clinical response.
Objectives To retrospectively evaluate the impact of comorbidities on treatment choice, 12-month clinical response, and 24-month retention rate in a cohort of RA patients treated with a first-line subcutaneous tumour necrosis factor alpha inhibitor (TNFi).
Methods Study population was extracted from a local registry which included all RA patients receiving adalimumab (ADA) or etanercept (ETN) as first-line biologic drug between January 2001 and December 2013. The prevalence of common RA comorbidities was computed and the study population was stratified according to Rheumatic Disease Comorbidity Index ([RDCI1] RDCI=0 vs RCDI≥1) for evaluating the role of comorbidities on the choice between ETN and ADA; the prescription of concomitant methotrexate (MTX); and the impact of comorbidities on 1-yearDisease Activity Score 28 (DAS28-ESR) remission and EULAR good-moderateresponse rates. The 24-month retention rate was computed by the Kaplan-Meiermethod and a Cox proportional hazard model was developed to examine the role ofRDCI and other baseline factors as predictors of TNFi persistence.
Results 310 RA patients (153ADA and 157 ETN) were included (female 82.1%, mean±standard deviation (SD) age 53.6±13.1 years, mean disease duration 11.6±9.2 years, mean baseline DAS 285.28±1.21, RF positivity 76.4%, mean HAQ 1.39±0.56). 41.2% of patients had atleast one comorbidity (overall mean RDCI 0.73) and the prevalence of conditions is reported in table 1. The proportion of patients with RCDI≥1 was similar in the subgroup receiving or not concomitant MTX (55.1% versus 44.8%, respectively; p=0.57) and similar (p=0.22) in patients treated with ADA (44.8%) or ETN (37.8%). No individual comorbidity was associated with the prescription of MTX or the choice between the two TNFis. No difference was found in therates of both EULAR good-moderate response (61.3% vs 53.7%, p=0.175) and DAS28-ESR remission (31.4% vs 27.2, p=0.463) according to baseline RDCI score. On the other hand, elevated RDCI is a predictor of biologic drug discontinuation (Hazard Ratio [HR] 1.17, confidence interval [95% CI] 1.00-1.37;p=0.04), where as treatment with ETN (HR 0.50, 95% CI 0.35-0.71; p<0.001) and concomitant MTX (HR 0.57, 95% CI 0.40-0.81; p=0.002) were both associated with a lower risk of TNFi withdrawal.
Conclusions in our real-life experience, the baseline presence of comorbidity seemed to not influence the prescription of concomitant MTX and to not drive the choice between ADA and ETN. Comorbidities did not affect 1-year clinical response, but were associated with a higher risk of TNFi discontinuation over a 2-year follow-up period. The use of ETN and concomitant treatment with MTX were both strong predictors of drug persistence.
Reference: 1. England BR, Sayles H, Mikuls TR, et al. Validation of the rheumatic diseasecomorbidity index. Arthritis Care Res 2015;67(6):865-72.
Disclosure of Interest: None declared
