Rheumatoid arthritis

Pandemic-inspired switch in RA treatment leads to worse outcomes

Adjusting biologic treatments for RA patients in response to the coronavirus pandemic is not as simple as it may seem, a study by UK rheumatologists suggests.

Most patients who switched from an intravenous to a subcutaneous delivery of abatacept or tocilizumab in order to reduce face-to-face hospital visits preferred to switch back, largely due to worsening symptoms, their small study found.

“The COVID-19 pandemic has seen profound adaptations made to rheumatology practice,” wrote authors led by Dr Rishi Gupta, of the department of rheumatology at University College London Hospitals, in a letter in Rheumatology.

Earlier in 2020, the National Institute for Health and Care Excellence (NICE) published COVID-19 guidelines proposing that clinicians consider switching RA patients from IV biologic disease-modifying anti-rheumatic drugs (DMARDs) to SC forms, in order to minimise in-hospital contact.

The authors identified a total of 250 patients receiving either IV abatacept or tocilizumab, delivered once every four weeks; they were considered candidates to switch to the weekly SC formulation if they had stable disease, were receiving a standard dose, had not had the same drug delivered subcutaneously before, and had no changes to their therapy in the previous three months.

Using a joint decision-making approach between doctor and patient, only 32 patients eventually switched formulations; 14 of these were receiving abatacept, and 18 were receiving tocilizumab. Those who did not switch cited the need to self-administer injections, among other objections.

A total of 29 of the 32 patients completed questionnaires assessing the switch. Of these, 77% (10 of 13) patients receiving abatacept and 88% (14 of 16) patients receiving tocilizumab indicated that they wanted to switch back from SC to IV delivery.

In the abatacept patients, 60% of those who wanted to switch back described worsening joint pain, stiffness, and swelling; this was reflected in worsening scores on the Routine Assessment of Patient Index Data 3 (RAPID3) questionnaire.

They had significantly worse total RAPID3 score (11.08 to 15.43, where higher numbers are worse; P = 0.01), as well as worse scores for functional ability (3.63 to 4.63, P = 0.04), pain (4.55 to 6.05, P = 0.04), and global wellbeing (0.90 to 4.75, P = 0.01).

Similar results were seen with tocilizumab, where total RAPID3 scores rose (8.66 to 11.8, P = 0.01) along with those for functional ability (2.99 to 3.51, P = 0.02) and global wellbeing (2.61 to 3.71, P = 0.02).

Along with worsening symptoms, some patients cited preferences for monthly administration over weekly and for seeing a healthcare professional in a hospital as reasons for wanting to switch back.

“It is tempting to speculate that a reduction in face-to-face interactions with healthcare professionals may have influenced the worsening disease activity as assessed by patient-reported outcome measures,” the authors wrote.

They concluded that switching from IV to SC versions of these agents should not be mandatory “and perhaps not even advisable” in any similar future situations.

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