Treatment Persistence and Clinical Outcomes of Tumor Necrosis Factor Inhibitor Cycling or Switching to a New Mechanism of Action Therapy: Real-world Observational Study of Rheumatoid Arthritis Patients in the United States with Prior Tumor Necrosis Factor Inhibitor Therapy

Adv Ther. 2017 Aug;34(8):1936-1952. doi: 10.1007/s12325-017-0578-8

This retrospective, observational study used a real-world US clinical database to demonstrate greater effectiveness of switching to a therapy with an alternative mechanism of action (MOA) vs cycling between TNF inhibitors (TNFis) in patients in which TNFi therapy has failed.Between 1 April 2010 and 31 March 2015, a total of 613 of the observed patients failed a TNFi therapy and then either cycled to another TNFi therapy (54.2%) or switched to a therapy with an alternative MOA (45.8%). The most common therapy to cycle to was adalimumab (23.0%), and the most common therapy to switch to was rituximab (14.7%). Mean 1-year change in baseline CDAI, DAS-28 (CRP/ESR) and RAPID 3 (Routine Assessment of Patient Index Data 3) were used to examine difference in improvement between the two groups.The 1-year mean reduction in CDAI was greater in the MOA switchers. This was initially a significant difference compared with the TNFi cyclers. However, once the baseline CDAI was accounted for, the difference was not significant. Amongst the patients with moderate or high disease activity at baseline, those who switched to a new MOA therapy were more likely to achieve minimal clinically important difference (MCID) in CDAI. The MOA switchers also demonstrated longer persistence of treatment compared with the TNFi cyclers, because the TNFi cyclers had a higher rate of swapping therapies.This study suggests that a more evidence-based approach to switching therapy versus cycling is needed in the management of patients with RA.