Patients more likely to achieve sustained RA remission on biological vs. triple therapy
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Patients with rheumatoid arthritis who start biological therapy after failing methotrexate are about two times more likely to be adherent and achieve sustained remission at 1 and 2 years than with triple therapy, according to data.
However, writing in Arthritis & Rheumatology, the researchers added that, in those who remained on therapy, the two treatment strategies demonstrated similar effectiveness at achieving sustained remission during the same time period.
“Methotrexate, currently regarded an anchor drug in RA, is sufficient as monotherapy in 25-40% of patients,” Meliha C. Kapetanovic, MD, PhD, of Lund University and Skåne University Hospital, in Sweden, and colleagues wrote. “Alternative treatment regimens include conventional triple therapy or adding of a biological [disease-modifying antirheumatic drug] (bDMARD) to methotrexate. Patients on triple therapy reported numerically higher total number of adverse events and discontinued their treatment due to adverse events more often, whereas the risk for serious infections is higher for biological therapies.”
“Despite the introduction of biosimilars, biological therapy is still more expensive than triple therapy, and comparisons between these strategies are relevant for patients with contraindications to biological therapies and also with regards to the allocation of health care resources,” they added.
To compare the real-life effectiveness of biological therapy to that of triple therapy in achieving sustained remission in patients with RA, Kapetanovic and colleagues analyzed data from the Swedish Rheumatology Quality Register. This national database includes information on patients aged 16 years and older diagnosed with RA from 56 rheumatology facilities throughout the country, according to the researchers.
“This is to our knowledge the first nationwide register study, using real-life data, comparing triple therapy to biological therapy with regards to sustained remission,” Kapetanovic told Healio Rheumatology.
For their own study, the researchers included a total of 1,502 registered between Jan. 1, 2000, and Dec. 31, 2012, who began biological therapy — a biological DMARD plus methotrexate — or triple therapy — methotrexate, sulfasalazine and hydroxychloroquine — as a first treatment after failing methotrexate alone. Among these patients, 1,155 received biological treatment while 347 were prescribed triple therapy. The researchers defined sustained remission as a DAS28 of less than 2.6 for at least 6 months, for the short-term outcome, and at least 24 months for the long-term outcome.
Kapetanovic and colleagues used propensity score adjusted regression analyses to compare the two groups at 1 and 2 years, both among all patients who started therapy and in those who remained with their therapy. They also used survival analyses to compared patients at any time during the follow-up period regardless of therapy retention.
According to the researchers, 64% and 43% of patients in the biological treatment group remained on therapy at 1 and 2 years respectively, compared with 52% and 35% in the triple therapy group.
In the crude, non-responder analysis — which included all patients who discontinued their initial therapy, counting them as non-responders from the point of discontinuation — 19% and 10% of patients in the biological group achieved short- and long-term remission, respectively, at year 1, while 21% and 12%, respectively, achieved the same at 2 years. Corresponding figures for the triple therapy group were 16% and 8%, respectively, at 1 year, and 15% and 11%, respectively, at 2 years.
In the crude, “completers analysis” — which excluded all patients who discontinued before 1 and 2 years — 27% and 14% of those in the biological group achieved sustained short- and long-term remission, respectively, at 1 year, while 38% and 22% demonstrated the same at 2 years. Corresponding figures for the triple therapy group were 30% and 15%, respectively, at 1 year, and 42% and 30%, respectively, at 2 years.
Among all patients starting therapy, the adjusted odds ratios for short- and long-term sustained remission at 1 year were 1.79 (95% CI, 1.18-2.72) and 1.86 (95% CI, 1‐3.48), respectively. At 2 years, the corresponding adjusted odds ratios were 1.92 (95% CI, 1.21‐3.06) and 1.62 (95% CI, 0.94‐2.79).
Among patients who remained on therapy, the adjusted odds ratios for short- and long-term sustained remission at 1 year were 1.12 (95% CI, 0.72‐1.75) and 1.31 (95% CI, 0.59‐2.16), respectively, and 0.85 (95% CI, 0.49‐1.47) and 0.76 (95% CI, 0.41‐1.39) at 2 years.
Meanwhile, the hazard ratios for short- and long-term sustained remission at any time during follow-up were 1.15 (95% CI, 0.91‐1.46) and 1.09 (95% CI, 0.77‐1.54), respectively.
“Biological therapy was more effective than triple therapy for patients remaining on therapy and experiencing sustained remission at 1 and 2 years from treatment start,” Kapetanovic told Healio Rheumatology. “However, we found similar effectiveness between the strategies for experiencing sustained remission among patients remaining on therapy after 1 and 2 years, which suggests that a subgroup of rheumatoid arthritis patients respond well to triple therapy.”
“We also found similar likelihoods for achieving sustained remission at any time during follow-up among patients started on either of these strategies, irrespective of therapy retention,” she added. “These are meaningful findings for patients with contraindications to biological therapy — such as those with recently diagnosed with malignancies or other comorbidities precluding the usage of biologics — and also of economic interest with regards to still-existing cost differences between the strategies, and hence resource allocations.”
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