Background/Purpose: The order of use of biologic agents after failing a TNF inhibitor is still a question for debate. Phase III trial data in TNF-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 (combined evaluation of efficacy and safety profile over time) of these agents in a clinical setting. Our objective is to evaluate if patients with rheumatoid arthritis (RA) treated with rituximab (RIT) after failing a first or a second anti-TNF agents (TNF-IR) have a different drug retention rate than patients similarly prescribed anti-TNF agents (pooled adalimumab, etanercept or infliximab) and compare the treatment strategies of using RIT as second or third biologic treatment .

Methods: Data from TNF-IR RA patients prescribed adalimumab (ADA), etanercept (ETA), infliximab (INF) or rituximab (RIT) as second or third biologic agents on or after January 1^st 2007 was extracted and subjects taking either ADA, ETA or INF were pooled to form the anti-TNF cohort. Baseline demographics included age, disease duration, HAQ-DI, fatigue and pain visual analog scale evaluations (VAS), TJC, SJC, DAS 28 ESR and SDAI. Five-year drug retention rates were estimated and compared using Kaplan-Meier survival estimates. Statistical analysis was performed using SAS version 9.3. RHUMADATA® is a clinical database and registry used in daily clinical practice at the IRM, CORQ and CREQ.

Results: The data from 226 RA patients were extracted, 153 and 73 having respectively failed a first and a second anti-TNF agent. No clinically significant differences in baseline variables were observed between treatment groups in second and third intention. The 5 year retention rates of second line RIT and anti-TNF use were 74% and 36% respectively (Log-rank p=0.002). In patients having failed two anti-TNF, subsequent use of RIT and anti-TNF agents respectively demonstrated 5 year retention rates of 48% and 24% (Log-rank p=0.004). Although numerically superior (74% vs 48%) second line use of RIT did not reach statistical difference when compared to third line usage.

Conclusion: As a second line agent, in TNF-IR patients, RIT demonstrates a better 5 year retention rate than anti-TNF agents. As third line therapy, RIT is also statistically superior to anti-TNF agents. Although no statistical difference was demonstrated between second and third line RIT use, it is evident that positioning RIT as second line offers a better long term outcome.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/use-of-rituximab-compared-to-anti-tnf-agents-as-second-and-third-line-therapy-in-patients-with-rheumatoid-arthritis-a-report-from-the-rhumadata-clinical-database-and-registry/