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Effectiveness of switching between TNF inhibitors in ankylosing spondylitis: data from the NOR-DMARD register
  1. E Lie1,
  2. D van der Heijde1,2,
  3. T Uhlig1,
  4. K Mikkelsen3,
  5. E Rødevand4,
  6. W Koldingsnes5,
  7. C Kaufmann6,
  8. T K Kvien1
  1. 1Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  2. 2Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
  3. 3Lillehammer Hospital for Rheumatic Diseases, Lillehammer, Norway
  4. 4Department of Rheumatology, St Olavs Hospital, Trondheim, Norway
  5. 5Department of Rheumatology, University Hospital of Northern Norway, Tromsø, Norway
  6. 6Department of Rheumatology, Buskerud Central Hospital, Drammen, Norway
  1. Correspondence to Dr E Lie, Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vinderen, N-0319 Oslo, Norway; elisabeth_lie{at}


Objective To assess the effectiveness of switching to a second tumour necrosis factor inhibitor (TNFi) in patients with ankylosing spondylitis (AS).

Methods Data were extracted from an ongoing longitudinal observational multicentre study in Norway. This study included anti-TNF naïve patients with AS starting treatment with a TNFi as well as treatment with a second TNFi in these same patients. Effectiveness data and 2-year drug survival were compared between switchers and non-switchers and within switchers (first and second TNFi).

Results 514 anti-TNF naïve patients with AS were included; 77 patients switched to a second TNFi while 437 patients did not switch. The percentages of non-switchers using etanercept, infliximab or adalimumab were 53%, 32% and 15%, and the percentages of first and second TNFi in the switchers were 42%, 53% and 5% and 40%, 23% and 36%, respectively. The reason for switching was insufficient response (IR) in 30, adverse events (AEs) in 44 and not reported in 3 patients. Baseline disease activity was similar between the groups. Three-month BASDAI 50 and ASAS 40 responses were achieved by 49% and 38% of non-switchers, by 25% and 30% of switchers after the first TNFi and by 28% and 31% after the second TNFi. The 3-month disease activity level was higher for switchers on the second TNFi than for non-switchers. Drug withdrawal rate was higher during the second TNFi among switchers than for non-switchers (p=0.001). No difference was found in the effectiveness of the second TNFi between switchers due to IR and AE.

Conclusion This study confirms that switching to a second TNFi can be effective in AS and can be as useful as in rheumatoid arthritis, although overall effectiveness seems to be somewhat lower than in non-switchers.

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  • Funding The work was supported by Eastern Norway Regional Health Authority. The Norwegian disease-modifying antirheumatic drug study has received unrestricted grant support from Abbott, Amgen, Wyeth, Aventis, MSD, Schering-Plough/Centocor, BristolMyers Squibb, Roche and the Norwegian Directorate for Health and Social Affairs.

  • Ethics approval This study was conducted with the approval of the regional ethics committee and by the Data Inspectorate. Patients gave written informed consent before participation.

  • Competing interests The NOR-DMARD register is financially supported by pharmaceutical companies but the sponsors are not involved in the analyses and presentation of data. Most of the authors have received speaker and/or consultancy honoraria from companies marketing biological DMARDs.

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