Rheumatoid arthritis

Frequent biologic switching as clinicians chase best outcomes in RA: OPAL


Rheumatologists are continually evolving treatment paradigms to get the best outcomes for their patients with rheumatoid arthritis, according to a review of biologic use between 1997 and 2015.

The data from almost 3,000 adults in the Optimising Patient Outcomes in Australian Rheumatology (OPAL) database showed median persistence on individual biologics (bDMARDs) was for a relatively short period of 0.7 years (range 0-11.8 years).

Most patients had only one episode of biologic treatment although up to eight episodes of treatment were used.

The most commonly prescribed bDMARDs during the study period were etanercept (27.6%) and adalimumab (22.3%).

However rituximab and tocilizumab had the longest duration of treatment (5.5 and 1.7 years respectively).

Lead author Dr Dave Nicholls from the University of the Sunshine Coast and Coast Joint Care in Queensland, told the limbic the available data could not explain the relatively short duration of treatment or why the biologic treatment was changed.

“We believe that probably represents the fact that rheumatologists are continually trying to get the best drug for their patients.”

“Just because a patient doesn’t continue on a drug doesn’t necessarily mean it’s a failure. It may mean that it partially worked but they were searching for the Holy Grail, which is the perfect treatment.”

“And because we are relatively spoilt in Australia with our choices, we suspect but can’t prove that one of the explanations for the short duration is that rheumatologists are changing treatments frequently because they want to do better for the patients.”

He said most people who switch biologics, do so within the first two years.

The study found 74% of bDMARDs were used in combination with methotrexate; a further 16% in combination with other conventional DMARDs. Only 10% of the biologics were administered as monotherapy.

“The published data has shown for a long time that if you are on a biologic, you are much better off to be on methotrexate with that biologic and if you can’t be on methotrexate, you are still better off to be on something else like leflunomide or sulfasalazine.”

Patients’ scores for both DAS28 and CDAI showed moderate to high disease activity before initiation to a biologic and low disease or remission at week 24.

“So 90% of patients here are using biologics in combination. Australian rheumatologists are showing they are up to date with best practice which is that we are trying to treat people to target using the guidelines, that we are aiming for low disease and we will chase the best treatment for our patients.”

Dr Nicholls said Roche funded the study although the pharmaceutical company had no control over the protocol, the data or the writing of the paper.

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