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Abstract Number: 1430

Switching from Synthetic to Biologic Dmards – Is There an Insufficient Use of Methotrexate?

Lisa Baganz1, Adrian Richter1, Yvette Meißner2, Matthias Schneider3, Anke Liebhaber4, Ilka Schwarze5, Anja Strangfeld6 and Angela Zink7, 1German Rheumatism Research Center, Berlin, Germany, 2Programme Area Epidemiology, German Rheumatism Research Center, Berlin, Germany, 3Department of Rheumatology, Univ. Duesseldorf, Duesseldorf, Germany, 4Rheumatologist, Halle, Germany, Halle, Germany, 5Rheumatologist, Leipzig, Germany, Leipzig, Germany, 6Epidemiology, German Rheumatism Research Center, Berlin, Germany, 7German Rheumatism Research Centre and Charité University Medicine, Berlin, Germany

Meeting: 2017 ACR/ARHP Annual Meeting

Date of first publication: September 18, 2017

Keywords: Biologic agents, methotrexate (MTX), rheumatoid arthritis (RA) and treatment options

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Session Information

Date: Monday, November 6, 2017

Session Title: Rheumatoid Arthritis – Small Molecules, Biologics and Gene Therapy Poster II: Prognostic Factors, Imaging and Miscellaneous Reports

Session Type: ACR Poster Session B

Session Time: 9:00AM-11:00AM

Background/Purpose: A recent US-study suggests considerable underuse of MTX and too early switches to biologic (b)DMARDs1  before using a high MTX dose or changing the route of administration. We investigated doses of MTX, route of administration and time to treatment escalation with bDMARDs in Germany.

Methods: The biologics register RABBIT (Rheumatoid Arthritis: Observation of biologic therapy) comprises a control group of patients who were enrolled when starting csDMARDs after failure of at least one csDMARD therapy (mostly MTX monotherapy). We selected n=1,608 patients starting either with MTX monotherapy, MTX + another csDMARD or triple therapy (MTX plus hydroxychloroquine and sulfasalazin). In a sub-cohort of patients recruited between 2009 and 2013 (n=1,151) information about the route of administration was available.

Results:  1,210 patients (75.2%) were enrolled at start of MTX plus another csDMARD, 356 patients (22.1%) starting MTX monotherapy and 42 patients (2.6%) with triple therapy. The proportions of male and seropositive patients were higher in MTX combination and triple therapy (p<0.05). Disease severity (DAS28) at baseline and physical function were not significantly different. Larger differences were found in the sub-cohort: patients treated with subcutaneous (sc) MTX were significantly younger, had a higher DAS28, higher doses of glucocorticoids (GC) and less physical function at baseline (p<0.01).

Overall, 266 (16.5%) patients were escalated to a bDMARD within the 1st year of observation. Only 53 patients (3.3%) switched to a bDMARD within 3 months after enrollment; without an impact of calendar time (p=0.23). In recent years, escalation to bDMARD therapy occurred earlier (Fig. 1). The median time to a bDMARD was highest (p<0.01) in MTX monotherapy (366d) compared to MTX combination (266d) and triple therapy (150d).

In year one, the average doses of MTX did not vary between the treatment regimens: MTX mono (15.2mg), combination (15.6mg), triple (15.0mg). In patients who switched to a bDMARD, 28.2% 95%CI [23.0; 34.1] had prior high doses (>20 mg) of MTX and 54.1% [47.9; 60.2] had GC doses ≥5 mg/d which was significantly higher than in patients who maintained csDMARD therapy (MTX >20mg: 17.7% [15.7;19.9], GC ≥5mg: 32.3% [29.8; 34.9]). Stratified by route of administration, doses were significantly higher with sc MTX (16.8mg [16.4; 17.1]) vs. oral (14.8mg [14.5; 15.1]) but more patients (p<0.01) with sc MTX (21.6%) were switched to a bDMARD compared to oral MTX (10.9%).

Conclusion:

Our data suggest that German rheumatologists use different strategies after insufficient response to MTX before switching to a bDMARD: MTX dose increase, change to sc MTX, combination with other csDMARDs or increase in GC dose. The results of the US-study1 could not be confirmed. 

1 Rohr MK, et al. "The Underuse of Methotrexate in the treatment of RA: […]" Arthritis Care & Research 2016, Nov 18, epub.


Disclosure: L. Baganz, None; A. Richter, Pfizer Inc, 5; Y. Meißner, None; M. Schneider, None; A. Liebhaber, None; I. Schwarze, None; A. Strangfeld, BMS, MSD, Pfizer, Roche, Sanofi-Aventis, 8; A. Zink, AbbVie, BMS, MSD, Pfizer, Roche, UCB, 8.

To cite this abstract in AMA style:

Baganz L, Richter A, Meißner Y, Schneider M, Liebhaber A, Schwarze I, Strangfeld A, Zink A. Switching from Synthetic to Biologic Dmards – Is There an Insufficient Use of Methotrexate? [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/switching-from-synthetic-to-biologic-dmards-is-there-an-insufficient-use-of-methotrexate/. Accessed January 17, 2021.
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