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Movahedi M, Choquette D, Coupal L, Cesta A, Li X, Keystone EC, Bombardier C, Investigators O. Discontinuation of tofacitinib and TNF inhibitors in patients with rheumatoid arthritis: analysis of pooled data from two registries in Canada. BMJ Open 2023; 13:e063198. [PMID: 36878650 PMCID: PMC9990670 DOI: 10.1136/bmjopen-2022-063198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
OBJECTIVES The similarity in retention of tumour necrosis factor inhibitors (TNFi) and tofacitinib (TOFA) was previously reported separately by the Ontario Best Practices Research Initiative and the Quebec cohort Rhumadata. However, because of small sample sizes in each registry, we aimed to confirm the findings by repeating the analysis of discontinuation of TNFi compared with TOFA, using pooled data from both these registries. DESIGN Retrospective cohort study. SETTING Pooled data from two rheumatoid arthritis (RA) registries in Canada. PARTICIPANTS Patients with RA starting TOFA or TNFi between June 2014 and December 2019 were included. A total of 1318 patients were included TNFi (n=825) or TOFA (n=493). OUTCOME MEASURES Time to discontinuation was assessed using Kaplan-Meier survival and Cox proportional hazards regression analysis. Propensity score (PS) stratification (deciles) and PS weighting were used to estimate treatment effects. RESULTS The mean disease duration in the TNFi group was shorter (8.9 years vs 13 years, p<0.001). Prior biological use (33.9% vs 66.9%, p<0.001) and clinical disease activity index (20.0 vs 22.1, p=0.02) were lower in the TNFi group.Discontinuation was reported in 309 (37.5%) and 181 (36.7%) TNFi and TOFA patients, respectively. After covariate adjustment using PS, there was no statistically significant difference between the two groups in discontinuation due to any reason HR=0.96 (95% CI 0.78 to 1.19, p=0.74)) as well as discontinuation due to ineffectiveness only HR=1.08 (95% CI 0.81 to 1.43, p=0.61)).TNFi users were less likely to discontinue due to adverse events (AEs) (adjusted HRs: 0.46, 95% CI 0.29 to 0.74; p=0.001). Results remained consistent for firstline users. CONCLUSIONS In this pooled real-world data study, the discontinuation rates overall were similar. However, discontinuation due to AEs was higher in TOFA compared with TNFi users.
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Affiliation(s)
- Mohammad Movahedi
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- IHMPE, Univeristy of Toronto, Toronto, Ontario, Canada
| | - Denis Choquette
- Department of Rheumatology, Institut de Rhumatologie de Montréal, Montreal, Québec, Canada
| | - Louis Coupal
- Department of Rheumatology, Institut de Rhumatologie de Montréal, Montreal, Québec, Canada
| | - Angela Cesta
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Xiuying Li
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Edward C Keystone
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Claire Bombardier
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- IHMPE, Univeristy of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Obri Investigators
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
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Sepriano A, Kerschbaumer A, Bergstra SA, Smolen JS, van der Heijde D, Caporali R, Edwards CJ, Verschueren P, de Souza S, Pope J, Takeuchi T, Hyrich K, Winthrop KL, Aletaha D, Stamm T, Schoones JW, Landewé RBM. Safety of synthetic and biological DMARDs: a systematic literature review informing the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis 2023; 82:107-118. [PMID: 36376026 DOI: 10.1136/ard-2022-223357] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To perform a systematic literature review (SLR) concerning the safety of synthetic(s) and biological (b) disease-modifying antirheumatic drugs (DMARDs) to inform the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis (RA). METHODS SLR of observational studies comparing safety outcomes of any DMARD with another intervention in RA. A comparator group was required for inclusion. For treatments yet without, or limited, registry data, randomised controlled trials (RCTs) were used. RESULTS Fifty-nine observational studies addressed the safety of DMARDs. Two studies (unclear risk of bias (RoB)) showed an increased risk of serious infections with bDMARDs compared with conventional synthetic (cs)DMARDs. Herpes zoster infections occurred more with JAKi than csDMARDs (adjusted HR (aHR): 3.66) and bDMARDs (aHR: 1.9-2.3) (four studies, two low RoB). The risk of malignancies was similar across bDMARDs (five studies) and with tofacitinib compared with bDMARDs (one study, low RoB). The risk of major adverse cardiovascular events (MACE) was similar with bDMARDs and tofacitinib (two studies, one low RoB). Thirty studies reported safety from RCTs, with one, designed to evaluate safety, showing that malignancies (HR (95% CI): 1.48 (1.04 to 2.09)) and MACE (HR (95% CI): 1.33 (0.91 to 1.94)) occurred numerically more frequently with tofacitinib (5 mg and 10 mg doses combined) than with TNFi in patients with cardiovascular risk factors. In this study, the risk of venous thromboembolism (VTE) was higher with tofacitinib 10 mg than with TNFi. CONCLUSION The safety profile of bDMARDs was further demonstrated. Whether the difference in incidence of malignancies, MACE and VTE between tofacitinib and TNFi applies to other JAKi needs further evaluation.
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Affiliation(s)
- Alexandre Sepriano
- CHRC Campus Nova Medical School, Lisboa, Portugal .,Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine, Medical University of Vienna, Wien, Austria
| | | | - Josef S Smolen
- Division of Rheumatology, Department of Medicine, Medical University of Vienna, Wien, Austria.,2nd Department of Medicine, Hietzing Hospital, Wien, Austria
| | | | - Roberto Caporali
- Department of Clinical Sciences and Community Health, ASS G. Pini, University of Milan, Milano, Italy.,Department of Rheumatology, ASST PINI-CTO, Milan, Italy
| | - Christopher J Edwards
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Patrick Verschueren
- Rheumatology, KU Leuven University Hospitals, Leuven, Belgium.,Engineering Research Centre, Lueven, Belgium
| | - Savia de Souza
- Patient Research Partner Network, European Alliance of Associations for Rheumatology, Zurich, Switzerland
| | - Janet Pope
- Medicine, Division of Rheumatology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Japan.,Saitama Medical University, Iruma-gun, Japan
| | - Kimme Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - Kevin L Winthrop
- School of Public Health, Oregon Health & Science University, Portland, Oregon, USA
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine, Medical University of Vienna, Wien, Austria
| | - Tanja Stamm
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Wien, Austria.,Institute for Arthritis and Rehabilitation, Ludwig Boltzmann, Vienna, Austria
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert B M Landewé
- Amsterdam Rheumatology Center, Amsterdam University Medical Centres, Amsterdam, The Netherlands.,Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
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Durability of Response to Tocilizumab Therapy in Rheumatoid Arthritis: Data from the US-Based Corrona Rheumatoid Arthritis Registry. Rheumatol Ther 2021; 8:467-481. [PMID: 33630272 PMCID: PMC7991054 DOI: 10.1007/s40744-021-00285-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/23/2021] [Indexed: 11/06/2022] Open
Abstract
Introduction Understanding the durability of response to treatment and factors associated with failure to maintain response in a real-world setting can inform treatment decisions for patients with rheumatoid arthritis (RA). The aim of this study was to analyze durability of response to tocilizumab (TCZ) and factors associated with durability among US patients with RA in routine clinical practice.
Methods TCZ initiators in the Corrona RA Registry were included. Durability of response was defined as maintaining continuous TCZ treatment and either an improvement of at least minimum clinically important difference (MCID) in Clinical Disease Activity Index (CDAI) score or low disease activity (LDA). Secondary analyses included patients treated with intravenous (IV) TCZ and excluded those who discontinued TCZ without reporting reasons for discontinuation. Durability was calculated with Kaplan–Meier survival analysis. Cox proportional hazards modeling identified factors associated with durability. Results Among 1789 TCZ initiators, 466, 272, and 162 were persistent (with or without durable response) with follow-up visits at 1, 2, and 3 years, respectively. Median MCID durability of response in CDAI was > 50% after 36 months overall, 26 months for TCZ-IV, and > 50% after 36 months for those with known reasons for discontinuation; longer durability was associated with increased duration of RA and higher baseline CDAI score and shorter durability with history of malignancy and history of diabetes. Median LDA durability of response was 13.0 months overall, for TCZ-IV, and for those with known reasons for discontinuation; shorter durability was associated with history of malignancy, history of diabetes, and higher baseline CDAI score. Conclusions Median durability of response to TCZ in RA was > 3 years when defined as maintenance of MCID in CDAI score and > 1 year with the more stringent criteria of maintenance of LDA. Trial Registration ClinicalTrials.gov identifier, NCT01402661
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