Treatment with infliximab (Remicade) when etanercept (Enbrel) has failed or vice versa: data from the STURE registry showing that switching tumour necrosis factor alpha blockers can make sense

Abstract

Objective: When one TNFalpha blocker (etanercept or infliximab) has failed, to determine whether it makes sense to treat patients with the other.

Patients and methods: Since 1999 patients treated with etanercept or infliximab have been systematically followed up at our institution in the STURE database. We identified 31 patients who had received both agents.

Results: Eighteen patients received etanercept first; discontinuation was mostly due to lack of efficacy. DAS28 values had improved only slightly with etanercept, with a mean (SEM) best DAS28 value of 4.8 (0.6). After switching to infliximab, the mean best DAS28 was 3.6 (0.6)-significantly better than the previous result (p<0.05). Similarly, the mean best ACR-N during etanercept treatment was 17.2 (6.65) and during subsequent infliximab treatment 40.4 (10.6) (p = 0.08). Thirteen patients received infliximab first; discontinuation was mainly due to adverse events. The best DAS28 value achieved during etanercept was 3.6 (0.4) compared with 4.1 (0.4) for infliximab (p<0.05), but the change in DAS28 was not different and ACR-N were similar for infliximab and etanercept in this group.

Conclusion: For patients with insufficient efficacy from etanercept, treatment with infliximab provided better results, suggesting that a trial of infliximab is reasonable for such patients. For patients who discontinued infliximab owing to adverse events, treatment with etanercept gave at least similar clinical efficacy. Taken together, these data provide support for a trial of the reciprocal TNFalpha blocker in patients when one such agent has failed.

Figure 1

(A) Disease activity by DAS28 in patients treated first with etanercept, then with infliximab. Values shown are the mean value at baseline (before etanercept treatment), mean best value during etanercept treatment, mean value at last visit while on etanercept (when the decision to switch was made), mean best value with infliximab. Comparisons are by paired two tailed Student's t test. (B) Swollen joint count in patients treated first with etanercept, then with infliximab. Values shown are the means at baseline and after three months for each treatment. Comparisons are by paired two tailed Student's t test.

Figure 2

(A) Disease activity by DAS28 in patients treated first with infliximab, then with etanercept. Values shown are the mean value at baseline (before infliximab treatment), mean best value during infliximab treatment, mean value at last visit while on infliximab (when decision to switch was made), mean value just before starting etanercept treatment, and mean best value on etanercept. Comparisons are by paired two tailed Student's t test. (B) Swollen joint count in patients treated first with infliximab, then with etanercept. Values shown are the means at baseline and after three months for each treatment. Comparisons are by paired two tailed Student's t test.