Article Text
Abstract
Background Multiple biologic and targeted synthetic disease-modifying rheumatic drugs (b/tsDMARDs) are approved for the management of rheumatoid arthritis (RA), including TNF inhibitors (TNFi), bDMARDs with other modes of action (bDMARD-OMA) and Janus kinase inhibitors (JAKi). Combination of b/tsDMARDs with conventional synthetic DMARDs (csDMARDs) is recommended, yet monotherapy is common in practice.
Objective To compare drug maintenance and clinical effectiveness of three alternative treatment options for RA management.
Methods This observational cohort study was nested within the Swiss RA Registry. TNFi, bDMARD-OMA (abatacept or anti-IL6 agents) or the JAKi tofacitinib (Tofa) initiated in adult RA patients were included. The primary outcome was overall drug retention. We further analysed secondary effectiveness outcomes and whether concomitant csDMARDs modified effectiveness, adjusting for potential confounding factors.
Results 4023 treatment courses of 2600 patients were included, 1862 on TNFi, 1355 on bDMARD-OMA and 806 on Tofa. TNFi was more frequently used as a first b/tsDMARDs, at a younger age and with shorter disease duration. Overall drug maintenance was significantly lower with TNFi compared with Tofa [HR 1.29 (95% CI 1.14 to 1.47)], but similar between bDMARD-OMA and Tofa [HR 1.09 (95% CI 0.96 to 1.24)]. TNFi maintenance was decreased when prescribed without concomitant csDMARDs [HR: 1.27 (95% CI 1.08 to 1.49)], while no difference was observed for bDMARD-OMA or Tofa maintenance with respect to concomitant csDMARDs.
Conclusion Tofa drug maintenance was comparable with bDMARDs-OMA and somewhat higher than TNFi. Concomitant csDMARDs appear to be required for optimal effectiveness of TNFi, but not for bDMARD-OMA or Tofa.
- rheumatoid arthritis
- biological therapies
- tocilizumab
- abatacept
- tumour necrosis alpha inhibitors
- comparative effectiveness research
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Funding The SCQM is financially supported by pharmaceutical industries and private donors. A list of financial supporters can be found on www.scqm.ch/sponsors. An Investigator-Initiated Research Grant was provided by Pfizer to the Swiss Clinical Quality Management in Rheumatic Diseases (SCQM) Foundation for a prospective observational study and development of this manuscript and to Pascal Zufferey, an institution investigator at the SCQM Foundation. A separate financial support from Pfizer was received by Pr. Axel Finckh, an employee of the Geneva University Hospital (HUG), for a distinct analysis in connection with analyses of the SCQM database and the development of this manuscript. The results of both analyses are included in this manuscript.
Competing interests Yes, there are competing interests for one or more authors and I have provided a Competing Interests statement in my manuscript.
Patient consent for publication Not required.
Ethical approval information This project was approved by the Geneva Ethical Committee (Protocole GE 10-089) on 31st of March 2015.
Provenance and peer review Not commissioned; externally peer reviewed.