Real-World Treatment and Care Patterns in Patients With Rheumatoid Arthritis Initiating First-Line Tumor Necrosis Factor Inhibitor Therapy in the United States

Abstract

Objective: Treatment guidelines for rheumatoid arthritis (RA) recommend targeting low disease activity or remission and switching therapies for patients not reaching those targets. We evaluated real-world use of disease activity measures, treatment discontinuation, and switching patterns among patients with RA initiating a first-line tumor necrosis factor inhibitor (TNFi).

Methods: Data from adult patients with RA initiating a first-line TNFi were collected from the American Rheumatology Network (January 2014-August 2021). The proportion of patients with recorded disease activity scores (Clinical Disease Activity Index [CDAI] or Routine Assessment of Patient Index Data 3 [RAPID3]) at TNFi initiation was assessed. Among patients with moderate or severe RA at TNFi initiation, reasons for discontinuation and subsequent advanced therapy were evaluated.

Results: Among TNFi initiators (n = 15,182), 44.8% recorded a CDAI/RAPID3 score at treatment initiation; of those who did not, 47.0% had recorded a tender and/or swollen joint count or pain score. Among patients with moderate or severe RA (n = 1,651), 52% discontinued their initial TNFi during follow-up, of which 15%, 46%, 28%, and 12% initiated the same TNFi, another TNFi, a non-TNFi biologic, or a Janus kinase inhibitor, respectively. The proportion of patients restarting the same TNFi or initiating another TNFi varied according to TNFi discontinuation reason.

Conclusion: In clinical practice, over half of patients with RA initiating a first-line TNFi did not have baseline disease activity assessments. Many patients cycled through TNFi despite citing lack of efficacy as the most common reason for discontinuation. Consistent, objective monitoring of treatment response and timely switch to effective therapy is needed in patients with RA.

Figure 1

Percentage of patients with a CDAI or RAPID3 assessment at first‐line TNFi initiation. CDAI, Clinical Disease Activity Index; RAPID3, Routine Assessment of Patient Index Data 3; TNFi, tumor necrosis factor inhibitor. ^aThe total scoring range for RAPID3 was 0–10 and 0–76 for CDAI, with higher scores indicating greater disease severity. ^bRAPID3 or CDAI category includes patients who had at least one of the two measures recorded.

Figure 2

Percentage of patients without a CDAI or RAPID3 assessment and with tender and/or swollen joint counts or pain score at TNFi initiation. CDAI, Clinical Disease Activity Index; RAPID3, Routine Assessment of Patient Index Data 3; TNFi, tumor necrosis factor inhibitor. ^aA total of 28 joints were assessed for tender and swollen joint counts; patient pain was scored on a 0–10 visual analog scale, with higher scores representing greater severity. ^bPain or Tender/Swollen Joint Count category includes patients who had at least one of the two measures recorded.

Figure 3

Primary reasons for discontinuation among patients with moderate to severe disease at baseline. ^aDiscontinuation related to tolerance stemmed from general medical issues such as side effects and development of a comorbidity related to tolerance issues (eg, hepatic or renal dysfunction). ^bDiscontinuation primarily related to nonefficacy and nontolerance issues included reasons such as payer‐related issues and/or patients’ wish to discontinue. It is possible that patients discontinuing primarily due to efficacy and/or tolerance also reported these nonefficacy/nontolerance issues, but they were not listed as the primary reasons for discontinuation. ^cReasons for discontinuation were not mutually exclusive and physicians could record more than one reason. ^dPatient concerns included patient's perception that treatment is not working and/or that patients report feeling worse on treatment. These data were categorized by medical scribes based on the patients’ clinical record and thus further granularity may not be available.

Figure 4

Percentage of patients with moderate to severe disease at baseline initiating a second therapy after discontinuing a first line TNFi by drug class. JAKi, Janus kinase inhibitor; TNFi, tumor necrosis factor inhibitor. ^aIncludes patients receiving golimumab by infusion or injection. ^bAmong those initiating a JAKi, 0.3% (n = 2) initiated baricitinib. ^cAmong those initiating a non‐TNFi biologic, 0.9% (n = 5) initiated sarilumab.

Figure 5

Subsequent therapy initiated by patients with moderate to severe disease at baseline after discontinuation of first line TNFi by the reason for discontinuation. JAKi, Janus kinase inhibitor; RA, rheumatoid arthritis; TNF, tumor necrosis factor; TNFi, TNF inhibitor. ^aLack of efficacy could be classified as continued disease activity; disease flares; functional difficulties; persistent inflammation, pain, or stiffness in back, legs, feet, joints, or hands; early morning stiffness; elevated C‐reactive protein levels; and eye pressure or vision changes related to RA.