Background/Purpose: In Australia the cost of biological/targeted synthetic DMARDs (b/tsDMARDs) for treatment of RA is subsidized if the patient has documented high levels of clinical/laboratory disease activity and has not responded to a pre-specified combination of conventional synthetic DMARDs, including methotrexate. Once eligible for subsidy the clinician can then prescribe the b/tsDMARD deemed most clinically appropriate until the desired level of disease control has been reached, with the available options being adalimumab, etanercept, certolizumab pegol, golimumab, infliximab, abatacept, tocilizumab, rituximab, tofacitinib, baricitinib and upadacitinib. The aim of this analysis was to explore b/tsDMARD treatment patterns and clinical priorities when managing RA in real-world rheumatology practice

Methods: Deidentified clinical data were sourced from the OPAL dataset, which is collected in a custom-built electronic medical record at the time of the consultation¹ by 110 rheumatologists in Australia. Prescribing patterns for patients >18 years with RA treated with a b/tsDMARD between Jan 2010-Dec 2014 and Jan 2015-Dec 2019 were included in the analysis. The software program Tableau^® was used to display data on medication initiation and cessation dates, and reasons for starting and stopping b/tsDMARDs, which is recorded at the time of the decision.

Results: At Dec 2019, there were 46,412 patients with RA in the dataset and 27% were prescribed b/tsDMARDs. Between 2010-2014, 63% of patients were prescribed a TNF inhibitor (TNFi), and 16%, 15% and 5% prescribed tocilizumab, abatacept and rituximab, respectively. Between 2015-2019, 46% of patients were prescribed a TNFi, followed by JAK inhibitors (JAKi) (28%), tocilizumab, abatacept, and rituximab (12%, 11% and 3%, respectively). TNFi cycling was frequently observed during 2010-2014 with 58% of patients receiving a TNFi in 1^st line switching to another TNFi in 2^nd line, which reduced to 40% between 2015-2019; however, TNFi cycling was still frequently observed despite the first TNFi being stopped due to lack of efficacy. From 2015, 33% of patients switched from a TNFi in 1^st line to a JAKi, and 57% switched from a JAKi in 1^st line to a TNFi. 20% of patients receiving a JAKi in 1^st line switched to another JAKi, which increased to 31% between Jan 2019-Dec 2019, citing lack of efficacy, AEs and better alternative.

Conclusion: Real-world treatment patterns for b/tsDMARDs are increasingly complex as more drugs with different modes of action (MOA) become available. There is a trend for earlier introduction of drugs with different MOA; however, TNFi cycling is still frequently observed despite evidence supporting increased persistence after switching MOA. Outcomes of JAKi cycling are uncertain and require further investigation. 

References:

¹ Littlejohn GO, Tymms KE, Smith T, Griffiths HT. Using big data from real-world Australian rheumatology encounters to enhance clinical care and research. Clin Exp Rheum Nov 2019.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/treatment-patterns-of-biologic-targeted-synthetic-dmards-for-the-management-of-rheumatoid-arthritis-in-australia-an-analysis-of-the-opal-dataset/