Biologic and Glucocorticoid Use after Methotrexate Initiation in Patients with Rheumatoid Arthritis

Abstract

Objective.Biologic therapies can improve disease control for patients with rheumatoid arthritis (RA) but may be both overused and underused. We aimed to identify predictors of greater use of biologic therapies and to identify factors associated with persistent glucocorticoid use.Methods.Using national US Veteran’s Affairs databases 2005–2016, we identified patients with RA receiving a first-ever prescription of methotrexate (MTX), requiring ≥ 6 months of baseline data. We evaluated predictors of biologic therapy initiation within 2 years of starting MTX and factors associated with baseline and persistent glucocorticoid use at 6–12 months using multivariable models.Results.Among 17,415 patients starting MTX, 3263 patients received biologic therapy within 2 years (20.6% 2-yr incidence). In adjusted analyses, biologic use was substantially lower in older patients [e.g., aHR 0.20 (95% CI 0.16, 0.26) for patients ≥ 80 vs < 50] and patients with more comorbidities [aHR 0.79 (95% CI 0.72, 0.87) for Charlson score ≥ 3 vs < 3]. Patients with heart failure [aHR 0.68 (95% CI 0.54, 0.84)], cancer [aHR 0.78 (95% CI 0.66, 0.92)], or who were nonwhite [aHR 0.79 (95% CI 0.72, 0.87)] were also less likely to receive a biologic. In contrast, baseline and persistent glucocorticoid use was similar across age groups and more common in patients with greater comorbidity.Conclusion.Biologic therapy is initiated less frequently in patients with RA who are older, have more comorbidities, and who are nonwhite. While biologics may be avoided in older and sicker patients because of safety concerns, glucocorticoid use is similar regardless of age and is more frequent in patients with comorbidities, with implications for patient outcomes.

Immunosuppression and the risk of readmission and mortality in patients with rheumatoid arthritis undergoing hip fracture, abdominopelvic and cardiac surgery

“…Interestingly, in our study, biologic-treated patients had lower rates of adverse outcomes than patients receiving methotrexate without a biologic before adjusting for potential confounders. Although biologic-treated patients may have more severe RA (in our study biologic-treated patients were more likely to be disabled), biologic-treated patients also tend to be younger and have fewer comorbidities,31 as we found here. The small differences in risk favouring biologic-treated patients after adjusting for confounders likely reflect some residual confounding rather than risks associated with methotrexate or protective effects of biologics—reassuringly, we found no difference in outcomes in patients receiving a biologic with versus without methotrexate (data not shown).…”

“…We cannot rule out the possibility that patients receiving biologics were selected differently for surgery (especially elective surgery) or were treated or monitored differently after surgery. Additionally, biologics may be avoided completely in patients who are frail or have comorbidities31 or survivorship bias could lead to a healthier biologic group, although we controlled for multiple comorbidities and measures of healthcare utilisation and attained good balance for measured covariates between exposure groups. Glucocorticoid results were more variable and there is even greater potential for unmeasured or residual confounding in these analyses.…”

Elicitation of Rheumatologist Preferences for the Treatment of Patients with Rheumatoid Arthritis After the Failure of a First Conventional Synthetic Disease-Modifying Anti-Rheumatic Agent

“…Our study demonstrates an overall conservative trend among physicians, with TNFi being the strategy of choice in 80% in these simulated patients with RA. This is aligned with the results of several publications on treatment pattern in real patients [23][24][25]. The exception to this trend was found in patients with a history of infection and pulmonary comorbidity, where ABA was the preferred option.…”

Low-dose Glucocorticoid Use Does Not Reduce Biologic Use in Early RA, Nor Do Biologics Reduce the Need for Glucocorticoids

“…Interestingly, but not surprisingly, baseline (49%) and persistent GC use (90%) was high in this study 1 . Minorities, smokers, hydroxychloroquine users, and those with psychological and pulmonary comorbidities or high inflammatory markers were higher GC users, whereas women and those with diabetes, higher BMI, or prior csDMARD use had lower GC use.…”

“…This study population was enriched for specified conditions of concern, allowing the authors to demonstrate the issues at play for RA patients with a poor prognosis profile, aptly demonstrating potential treatment challenges. Despite missing data on serology and absence of data on GC dosing, disease activity, and treatment response, this study demonstrates the treatment challenges in RA 1 . Whether the rate of bDMARD use in the cohort is high or low could be debated, but will remain unknown without determining how many patients reached treatment targets.…”