Background/Purpose: Data on patient-reported functional ability to evaluate the optimal strategy for patients who have failed to first TNFi is scarce. Patient-reported outcomes are a critical component of assessing whether clinicians are improving the wellbeing of patients. We conducted a systematic review and meta-analysis to evaluate the comparative effectiveness of two strategies, cycling versus swapping, on patient-reported functional ability and other patient-reported outcomes.

Methods: Four electronic databases were searched (MEDLINE, EMBASE, Cochrane Library, and Web of Sciences). Sources of gray literature (unpublished records) were searched through clinicaltrials.gov and other websites. The selection process, risk of bias assessment, and data extraction were performed by two independent reviewers. We included controlled trials evaluating patient reported outcomes in patients either cycling to a second TNFi or swapping to a targeted drug with an alternative mechanism of action. Other outcomes reported included pain, patient global assessment, fatigue, and quality of life.

Results: We included 13 studies reporting data on 4,394 patients. The reported cycling strategies were adalimumab, certolizumab, etanercept, golimumab, or infliximab; swapping strategies were abatacept, rituximab, tocilizumab, or tofacitinib. For the individual comparisons, TNFi versus disease modifying antirheumatic drug (DMARD), there was a statistically significant increase in functional ability from baseline to 14 weeks, favoring those patients receiving the cycling strategy (Mean Difference (MD) -0.20, 95% CI -0.34 to -0.06; scores ranging from 0 to 3). Differences favoring cycling when compared to a DMARD were also observed for pain, fatigue, and patient global assessment. Similarly, when comparing nonTNFi versus DMARD, there was a statistically significant increase in functional ability from baseline to 24 weeks, favoring those patients receiving the swapping strategy (MD -0.31, 95% CI -0.35 to -0.27; scores ranging from 0 to 3). Differences favoring cycling when compared to a DMARD were also observed for pain, sleep, fatigue, patient global, and quality of life (SF-36 physical and mental components). Three RCTs directly compared the two strategies. There was no statistically significant differences in the functional disability reported between those patients assigned to the cycling strategy compared with those assigned to the swapping strategy at 12, 24, 36 or 52 weeks (MD at 52 weeks -0.05, 95% CI -0.18 to 0.09; score ranging from 0-3).

Conclusion: Although evidence from previous reports suggest that swapping may be more effective than cycling when evaluating some clinical outcomes our results suggest that with the current evidence both strategies are equally effective in improving functional disability and other patient-reported outcomes.

« Back to 2018 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-comparative-effectiveness-of-cycling-tumor-necrosis-factor-inhibitor-tnfi-versus-swapping-to-a-nontnfi-on-patient-reported-functional-ability-of-patients-with-rheumatoid-arthritis/