For First-Line Monotherapy for RA, Etanercept Is Preferable, Analysis Finds

The improved efficacy of a biologic drug in combination with a conventional treatment in rheumatoid arthritis (RA) has been well demonstrated, but some biologic-naive patients are unable to tolerate drugs such as methotrexate. Limited data are available about which biologic to select for monotherapy in such patients, however. 
Kelly Davio
September 17, 2018
The improved efficacy of a biologic drug in combination with a conventional treatment in rheumatoid arthritis (RA) has been well demonstrated, but some biologic-naive patients are unable to tolerate drugs such as methotrexate. Limited data are available about which biologic to select for monotherapy in such patients, however. 

A recently published analysis, appearing in BMJ Open, used data from the Administrative Healthcare Database of Italy’s Lombardy region, as part of the RECord-linkage On Rheumatic Diseases (RECORD) study, to comparatively evaluate the persistence of treatment on different biologics used in monotherapy compared with combination therapy. 

Click to read more about monotherapy for rheumatoid arthritis.

Patients with RA in the RECORD study were assessed to identify 799 patients who had at least 1 delivery of a first-line biologic as monotherapy, and 3679 patients who received combination therapy in the first line. Biologics used included abatacept, adalimumab, certolizumab, etanercept, golimumab, infliximab, and tocilizumab. Rituximab was excluded due to local limitations on use. Monotherapy was associated with longer disease duration, hepatic and renal disease, heart failure, lower use of steroids, and lower use of nonsteroidal anti-inflammatory drugs. 

Combination therapy has been shown in many studies to be associated with a 21% lower risk of drug failure, but among those who received monotherapy, considering etanercept as a reference point, the adjusted hazard ratio [HR] for biologic failure was 1.28 for adalimumab (95% CI, 1.03-1.59) and 2.41 for infliximab (95% CI, 1.85-3.15). Abatacept was associated with a reduced through not statistically significant risk of failure, and tocilizumab was approximately equal with etanercept. Among combination therapies, only infliximab was statistically inferior to etanercept monotherapy. 

The authors of the analysis write that, while monotherapy is commonly observed, it is important to better understand the factors that drive monotherapy, such as comorbidities, body mass index, and higher disease activity.

The authors conclude that using biologics with conventional therapy is preferable to monotherapy, and further state that etanercept monotherapy should be preferred to infliximab and adalimumab when first-line monotherapy is necessary. 

Reference
Silvagni E, Bortoluzzi A, Carrara G. Comparative effectiveness of first-line biological monotherapy use in rheumatoid arthritis: a retrospective analysis of the RECord-linkage On Rheumatic Diseases study on health care administrative databases. BMJ Open.2018;8(9):e021447. doi: 10.1136/bmjopen-2017-021447.
 

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