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Patient characteristics influence the choice of biological drug in RA, and will make non-TNFi biologics appear more harmful than TNFi biologics.
Ann Rheum Dis. 2018 05; 77(5):650-657.AR

Abstract

OBJECTIVES

With the wide range of biological disease-modifying anti-rheumatic drugs (bDMARDs) available for treating rheumatoid arthritis (RA), and limited evidence to guide the choice for individual patients, we wished to evaluate whether patient characteristics influence the choice of bDMARD in clinical practice, and to quantify the extent to which this would bias direct comparisons of treatment outcome.

METHODS

Register-based study of all Swedish patients with RA initiating necrosis factor inhibitor (TNFi), rituximab, abatacept or tocilizumab in 2011-2015 as their first bDMARD (n=6481), or after switch from TNFi as first bDMARD (n=2829). Group differences in demographics, clinical characteristics and medical history were assessed in multivariable regression models. Predicted differences in safety and treatment outcomes were calculated as a function of patient characteristics, through regression modelling based on observed outcomes among patients with RA starting bDMARDs 2006-2010.

RESULTS

Patients starting non-TNFi were older than those starting TNFi, had lower socioeconomic status, higher disease activity and higher burden of diseases including malignancy, serious infections and diabetes. Differences were most pronounced at first bDMARD initiation. These factors were linked to treatment outcome independent of therapy, yielding worse apparent safety and effectiveness for non-TNFi biologics, most extreme for rituximab. Standardising to the age/sex distribution of the TNFi group reduced differences considerably.

CONCLUSIONS

There was significant channelling of older and less healthy patients with RA to non-TNFi bDMARDs, in particular as first bDMARD. Whether this channelling represents a maximised benefit/risk ratio is unclear. Unless differences in age, medical history and disease activity are accounted for, they will substantially confound non-randomised comparative studies of available bDMARDs' safety and effectiveness.

Authors+Show Affiliations

Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.Rheumatology Unit, Department of Medical Sciences, Uppsala University, Uppsala, Sweden.Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden.Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.Department of Public Health and Clinical Medicine, Rheumatology, Umeå University, Umeå, Sweden.Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden. Department of Rheumatology, Karolinska University Hospital, Stockholm, Sweden.No affiliation info available

Pub Type(s)

Evaluation Study
Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

29237621

Citation

Frisell, Thomas, et al. "Patient Characteristics Influence the Choice of Biological Drug in RA, and Will Make non-TNFi Biologics Appear More Harmful Than TNFi Biologics." Annals of the Rheumatic Diseases, vol. 77, no. 5, 2018, pp. 650-657.
Frisell T, Baecklund E, Bengtsson K, et al. Patient characteristics influence the choice of biological drug in RA, and will make non-TNFi biologics appear more harmful than TNFi biologics. Ann Rheum Dis. 2018;77(5):650-657.
Frisell, T., Baecklund, E., Bengtsson, K., Di Giuseppe, D., Forsblad-d'Elia, H., & Askling, J. (2018). Patient characteristics influence the choice of biological drug in RA, and will make non-TNFi biologics appear more harmful than TNFi biologics. Annals of the Rheumatic Diseases, 77(5), 650-657. https://doi.org/10.1136/annrheumdis-2017-212395
Frisell T, et al. Patient Characteristics Influence the Choice of Biological Drug in RA, and Will Make non-TNFi Biologics Appear More Harmful Than TNFi Biologics. Ann Rheum Dis. 2018;77(5):650-657. PubMed PMID: 29237621.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Patient characteristics influence the choice of biological drug in RA, and will make non-TNFi biologics appear more harmful than TNFi biologics. AU - Frisell,Thomas, AU - Baecklund,Eva, AU - Bengtsson,Karin, AU - Di Giuseppe,Daniela, AU - Forsblad-d'Elia,Helena, AU - Askling,Johan, AU - ,, Y1 - 2017/12/13/ PY - 2017/09/15/received PY - 2017/11/23/revised PY - 2017/11/27/accepted PY - 2017/12/15/pubmed PY - 2019/1/15/medline PY - 2017/12/15/entrez KW - dmards (biologic) KW - epidemiology KW - health services research KW - outcomes research KW - rheumatoid arthritis SP - 650 EP - 657 JF - Annals of the rheumatic diseases JO - Ann. Rheum. Dis. VL - 77 IS - 5 N2 - OBJECTIVES: With the wide range of biological disease-modifying anti-rheumatic drugs (bDMARDs) available for treating rheumatoid arthritis (RA), and limited evidence to guide the choice for individual patients, we wished to evaluate whether patient characteristics influence the choice of bDMARD in clinical practice, and to quantify the extent to which this would bias direct comparisons of treatment outcome. METHODS: Register-based study of all Swedish patients with RA initiating necrosis factor inhibitor (TNFi), rituximab, abatacept or tocilizumab in 2011-2015 as their first bDMARD (n=6481), or after switch from TNFi as first bDMARD (n=2829). Group differences in demographics, clinical characteristics and medical history were assessed in multivariable regression models. Predicted differences in safety and treatment outcomes were calculated as a function of patient characteristics, through regression modelling based on observed outcomes among patients with RA starting bDMARDs 2006-2010. RESULTS: Patients starting non-TNFi were older than those starting TNFi, had lower socioeconomic status, higher disease activity and higher burden of diseases including malignancy, serious infections and diabetes. Differences were most pronounced at first bDMARD initiation. These factors were linked to treatment outcome independent of therapy, yielding worse apparent safety and effectiveness for non-TNFi biologics, most extreme for rituximab. Standardising to the age/sex distribution of the TNFi group reduced differences considerably. CONCLUSIONS: There was significant channelling of older and less healthy patients with RA to non-TNFi bDMARDs, in particular as first bDMARD. Whether this channelling represents a maximised benefit/risk ratio is unclear. Unless differences in age, medical history and disease activity are accounted for, they will substantially confound non-randomised comparative studies of available bDMARDs' safety and effectiveness. SN - 1468-2060 UR - https://www.unboundmedicine.com/medline/citation/29237621/Patient_characteristics_influence_the_choice_of_biological_drug_in_RA_and_will_make_non_TNFi_biologics_appear_more_harmful_than_TNFi_biologics_ L2 - https://ard.bmj.com/cgi/pmidlookup?view=long&pmid=29237621 DB - PRIME DP - Unbound Medicine ER -