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In RA, should we kick the habit (of TNFi as first biologic)?
November 8 2015 4:33 PM ET — via RheumReports
Yazici et al (abstract #505) studied 1789 patient visits among 316 RA patients from the Arthritis Registry Monitoring Database (ARMD) which collects routine care data in RA with MDHAQ and patient global, pain, and RADAI scores. All patients were initiating their first biologic treatment. For biologic outcomes, infliximab was set as the comparator with a hazard ratio of 1. This work is an extension of previous data presented from their database but includes more biologics.
The best outcomes were mostly from NON-TNFi treatment. Adjusted hazard ratios compared to infliximab showed rituximab (HR 2.3), etanercept (HR 1.6) and abatacept (HR 1.5) to be superior, whereas numerically but not statistically, both adalimumab and tociluzimab were better than infliximab. Strange of course, as rituximab is not approved in many countries as a first-line biologic even though it performed the best.
The reasons for use of rituximab as a first-line advanced therapeutic were not collected. In general, rituximab is used as the 1st biologic in RA when there are special circumstances such as relative contraindications to TNFi and of course the profiling of use in patients with positive RF (perhaps and/or anti-CCP). Perhaps the response to treatment of these patients is different (but I suspect not and that it is generalizable to other RA patients who do not have some contraindications).
Some confounders were adjusted for such as age, sex, disease duration, baseline disease activity,etc. But, this was not a randomized study, so there could be confounding by indication (i.e., reasons for the rheumatologist to choose one drug over another that are unknown and not adjusted for), but with these real-world data in mind, maybe we should order our biologics differently and kick the habit of TNFi as first biologic in RA!
The next interesting analysis could be cost effectiveness comparisons between the different agents based on response and durability of 1st treatment (as your 1st is often your best – longest sustainability and deepest response).
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About the Author
Dr. Janet Pope
Dr. Janet Pope is Professor of Medicine at Western University and Division Head of Rheumatology. Dr. Pope's research interests include epidemiologic studies in scleroderma, classification criteria in systemic sclerosis, systemic lupus erythematosus and rheumatoid arthritis.
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