Background/Purpose: Current
recommendations for pharmacologic management of rheumatoid arthritis (RA)
advise dose titration or switching treatment if goals of remission or low
disease activity are not met.

Our objective is to describe factors
causing treatment change and choice of drug from non-biologic DMARD to a
biologic DMARD (bDMARD), and subsequent progression in bDMARD therapy, in
real-world practice.

Methods: Data
were drawn from the Adelphi 2014 RA Disease Specific Programme, a survey of
rheumatologists and their RA patients in France, Germany, Italy, Spain and UK. Rheumatologists
provided patient demographics, clinical details and treatment history including
reasons for switching treatment. In bDMARD-naïve patients physicians provided
reasons why they would initiate a bDMARD. Summary statistics were used to
describe the decision-process of physicians at varying stages of treatment, and
to compare bDMARD vs. non-bDMARD patients who were eligible for bDMARD therapy
at initiation of current therapy.

Results: 307
rheumatologists provided data for 2536 patients, 71% female, a mean age of 52.8
years and 72.6 months since diagnosis. 63.5% of patients had never received
bDMARD therapy (bDMARD naïve), 36.5% had received bDMARD therapy (33.9%
currently receiving, 2.6% on a treatment break or had discontinued). 24.8% of
patients had only ever received 1 bDMARD.

The main reasons prompting initiation of a bDMARD in
naïve patients were worsening of RA severity as assessed by the physician
(60.6%) and failure of non-bDMARD therapy (32.5%). bDMARD patients had been
diagnosed longer compared to bDMARD-eligible patients who had not received a bDMARD
(103.4 vs. 80.3 months), had a more severe condition at initiation of therapy
(% rheumatologist perceived ‘severe’: 51.7 vs. 26.5), experienced more pain at
initiation (mean score [1=none; 10=worst]: 7.1 vs. 6.4); all p<0.01). When
selecting which bDMARD therapy to prescribe first, physicians report ‘strong
overall efficacy’ as the main reason for bDMARD selection (70.8%) followed by
‘convincing efficacy in clinical trials’ (54.9%).

The main reasons for switching from previous bDMARD
to current bDMARD are physician assessed worsening of condition (45.8%) and
loss of response over time (38.4%). The main reasons for second bDMARD choice were
similar to first: strong overall efficacy (73.8%), convincing efficacy in
clinical trials (50.2%), and in addition ‘inhibits disease progression’
(50.2%). Reasons were relatively consistent regardless of bDMARD switched to
(TNF inhibitor (TNFi) or non-TNFi).

Conclusion:
Worsening
severity of RA, rather than high baseline RA activity, is the main reason for
treatment escalation regardless of the stage in the treatment pathway,
suggesting current treatment approaches are not sustainably maintaining disease
control in all patients.  Furthermore, there is a need for clinical and
laboratory biomarkers that could better inform the selection of first and
subsequent bDMARDs. These findings emphasise the importance of early and
optimum disease control where feasible, and physicians may therefore benefit
from additional guidance and clarity on appropriate sequencing of bDMARD
treatments.