Background/Purpose: The order of use of biologic agents is still a question for debate. Phase III trial data in MTX-IR patients show comparable efficacy results across biologic agents and limited head-to-head studies have been published. Prospective registries offer a unique opportunity to observe the effectiveness of these agents in a clinical setting. Our objectives are to evaluate if patients with rheumatoid arthritis (RA) treated with abatacept after failure to either a first line agent (MTX-IR) or a second line anti-TNF agents (TNF-IR) have a different drug survival rate than patients similarly treated with adalimumab, etanercept or infliximab. A secondary objective is to explore the role of MTX co-prescription.

Methods: RA patients prescribed a first biologic agent after January 1^st 2007 were included in the present analysis. Two cohorts were extracted, the first included all patients prescribed their first biologic agent, abatacept (ABA), adalimumab (ADA), etanercept (ETA) or infliximab (INF); the second included all patients failing their first biologic agent and switching to a second one. Baseline demographics for both cohorts included age, disease duration, HAQ-DI, fatigue and pain visual analog scale evaluation (VAS), TJC, SJC, DAS 28 ESR and SDAI. Person-years of treatment were also compared across biologic agents. Statistical analysis was performed using SAS version 9.3. RHUMADATA® is a clinical database and registry used daily in clinical practice at the IRM and the CORQ.

Results: A total of 493 patients were analysed, 339 were included in the first cohort and 154 composed the second cohort. No significant differences in baseline characteristics were noted between treatment groups. The 5 year retention rate of ABA, ADA, ETA and INF post MTX failure were 66%, 44%, 47% and 50% without significant statistical differences (Log-Rank p=0.35). When combining all biologics, the use of DMARDs did exhibit better drug survival than biologic monotherapy, 50% (combination therapy) vs. 33% (monotherapy). This difference however did not reach statistical significance (Log-Rank p=0.09). However, patients having failed a first anti-TNF agent had  a better 5 years drug survival rate if treated with ABA than those treated with ADA, ETA or INF as demonstrated by rates of 47% (ABA), 28%(ADA), 27% (ETA) and 13% (INF) (Log-Rank p=0.01).  

Conclusion: Abatacept, adalimumab, etanercept and infliximab after MTX failure have similar 5-years retention rates. Combination with methotrexate did not, however, demonstrate statistically significant improved 5-year retention. Prescribing abatacept after a previous TNF agent failure seems to offer a more favorable outcome.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/comparing-abatacept-to-adalimumab-etanercept-and-infliximab-as-first-or-second-line-agents-in-patients-with-rheumatoid-arthritis-experience-from-the-rhumadata-clinical-database-and-regis/