Real‐world persistence of initial targeted therapy strategy in monotherapy versus combination therapy in patients with chronic inflammatory arthritis

Abstract

ObjectiveThe persistence of biologic (b) and targeted synthetic (ts) disease‐modifying antirheumatic drugs(DMARDs) in monotherapy versus in combination with conventional synthetic (cs) DMARDs is still a controversial topic in rheumatic diseases. To clarify this issue, the retention of the initial treatment strategy of b/tsDMARD in combination with csDMARD versus monotherapy in rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) patients under real‐life conditions was evaluated. Factors associated with maintenance of the initial strategy were analysed.MethodsNested cohort study within the Spanish BIOBADASER III registry. Bivariate comparisons and multivariate Cox proportional hazards models were used for the analyses.ResultsA total of 2521 patients were included in the study. In the multivariate model, the initial strategy of combination therapy was associated with shorter persistence in patients with RA (hazard ratio [HR] 1.58;95% confidence interval [CI] 1.00–2.50; p = .049), PsA (HR 2.48; 95% CI 1.65–3.72) and AS (HR 16.77; 95% CI 7.37–38.16; p < .001), regardless of sex, time of disease progression, baseline disease activity, glucocorticoid use or type of b/tsDMARD. Overall, the combination strategy was associated with an increased incidence of adverse events (incidence rate ratio [IRR] 1.13; 95% CI 1.05–1.21).ConclusionsIn this real‐life study, the strategy of combining a b/tsDMARD with a csDMARD is associated with lower persistence and worse safety profile compared to monotherapy in RA and especially in PsA and AS, suggesting that combination therapy should be rethought as first choice in RA patients, but especially in PsA and AS patients.

No difference in clinical parameters and drug retention in PsA patients receiving b/tsDMARD monotherapy versus combination with methotrexate: data from the RABBIT-SpA registry

“… 3236 38 Recently, a cohort study from the Spanish BIOBADASER III registry demonstrated that combination therapy is associated with lower persistence compared with monotherapy PsA. 39 Furthermore, a recent investigation of cohorts from five different European countries presented inconsistent results of the potential beneficial use of MTX. 40 While a retrospective observational study using data from the US administrative database showed that the therapy with TNFi in combination with MTX was associated with increased persistence of the TNFi.…”

“…While there was no difference in the safety profile between the mono and combination therapy in our study, data from the Spanish registry showed that the addition of a csDMARD to a b/tsDMARD was associated with a significantly worse safety profile than b/tsDMARD monotherapy with infections being the adverse events with the highest increase. 39 …”