LAUSR

Background Many current guidelines rank abatacept (ABA), rituximab (RTX), tocilizumab (TOC), and the TNFi bDMARDs as equal in effectiveness for the treatment of RA, at least as second line therapies. This is mainly based on evidence from separate RCTs, with few direct comparisons and limited comparative effectiveness data from clinical practice. Objectives To describe outcomes in clinical practice among RA patients starting different bDMARDs as first bDMARD, and after switch from initial TNFi. Methods The Swedish Rheumatology Register was linked to nationwide registers with data on demographics and medical history. We included all patients with RA starting a first ever bDMARD, or switching to a new bDMARD after a TNFi as first bDMARD, in 2010 - 2014, with follow-up through 2015. Effectiveness was assessed at 1 year (±90 days) after starting therapy, and measured as 1) the proportion remaining on therapy, or the proportion remaining on therapy and with 2) Good EULAR response, 3) HAQ improvement >0.2, 4) no swollen or tender joints. Relative response was estimated with log-binomial regression adjusting for potential confounders. Results Patients starting non-TNFi were older than those starting a TNFi, had lower socioeconomic status, and more often a history of diseases including malignancy, serious infections, and diabetes. After switch from TNFi, those starting non-TNFi also had higher disease activity. Non-TNFi were associated with better drug survival and higher proportion reaching response outcomes compared to TNFi as first bDMARD. After switch from TNFi, RTX and TOC, but not ABA, were associated with significantly better drug survival and response. Differences remained after adjusting for identified potential confounders.Table 1. Status at 12 months among all patients with RA initiating a biologic DMARD 2010–2014 in Sweden TNFi RTX TOC ABA % % RR† % RR† % RR† First bDMARD N=5568 N=654 N=202 N=240 On drug 68.4 87.8 1.34 (1.27–1.41) 75.5 1.20 (1.09–1.31) 77.7 1.15 (1.05–1.27) On drug + EULAR Good resp. 26.1 31.1 1.42 (1.19–1.69) 53.1 2.03 (1.70–2.42) 34.3 1.37 (1.10–1.72) On drug + HAQ Improvement 26.7 39.2 1.64 (1.40–1.93) 45.0 1.54 (1.27–1.87) 36.8 1.37 (1.09–1.71) On drug + 28 Joint count = 0 20.3 22.4 1.13 (0.89–1.43) 30.9 1.60 (1.21–2.11) 22.8 1.26 (0.91–1.74) Switch from TNFi N=1840 N=408 N=320 N=256 On drug 57.7 80.2 1.48 (1.37–1.60) 73.0 1.36 (1.23–1.49) 65.1 1.11 (0.98–1.26) On drug + EULAR Good resp. 11.4 24.0 1.87 (1.41–2.49) 36.8 3.06 (2.37–3.94) 14.6 1.16 (0.76–1.76) On drug + HAQ Improvement 16.6 34.3 1.85 (1.49–2.30) 32.4 1.71 (1.33–2.19) 20.4 1.10 (0.78–1.53) On drug + 28 Joint count = 0 12.3 20.8 1.96 (1.43–2.70) 19.9 2.12 (1.48–3.02) 11.2 0.86 (0.48–1.52) †Adj. for region, sex, age, birth country, RF, dis. dur., HAQ, DAS28, co-medication, recent history of malignancy, infection, SSRI, and hospital days last 5 yrs. Conclusions Despite channeling of older and sicker individuals to non-TNFi-bDMARDs, treatment outcomes were in general better in these groups, particularly for TOC and RTX. In interpreting this, the risk of residual confounding should be remembered, and that we did not include safety or long term outcomes. Acknowledgements The ARTIS registry has been, or is, supported by agreements with Abbvie, BMS, MSD, Pfizer, Roche, Samsung, and UCB. Disclosure of Interest T. Frisell: None declared, M. Dehlin: None declared, D. Di Giuseppe: None declared, N. Feltelius: None declared, A. Kastbom Consultant for: Bristol-Myers Squibb, Pfizer, Roche, UCB, Paid instructor for: Bristol-Myers Squibb, Pfizer, Roche, UCB, C. Turesson Grant/research support from: Abbvie, Pfizer, Roche, Consultant for: MSD, Pfizer, Roche, Paid instructor for: Abbvie, Bristol-Myers Squibb, Janssen, MSD, Pfizer, Roche and UCB, J. Askling Grant/research support from: Abbvie, UCB, Pfizer, Merck, Samsung, Roche, Lilly