The impact of a csDMARD in combination with a TNF inhibitor on drug retention and clinical remission in axial spondylarthritis.

Nissen, Michael; Delcoigne, Bénédicte; Di Giuseppe, Daniela; Jacobsson, Lennart; Hetland, Merete Lund; Ciurea, Adrian; Nekvindova, Lucie; Iannone, Florenzo; Akkoc, Nurullah; Sokka-Isler, Tuulikki; Fagerli, Karen Minde; Santos, Maria Jose; Codreanu, Catalin; Pombo-Suarez, Manuel; Rotar, Ziga; Gudbjornsson, Bjorn; van der Horst-Bruinsma, Irene; Loft, Anne Gitte; Möller, Burkhard; Mann, Herman; ... (2022). The impact of a csDMARD in combination with a TNF inhibitor on drug retention and clinical remission in axial spondylarthritis. Rheumatology, 61(12), pp. 4741-4751. Oxford University Press 10.1093/rheumatology/keac174

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OBJECTIVES

Many axial spondylarthritis (axSpA) patients receive a conventional synthetic disease-modifying anti-rheumatic drug (csDMARD) in combination with a tumour necrosis factor inhibitor (TNFi). However, the value of this co-therapy remains unclear. The objectives were to describe the characteristics of axSpA patients initiating a first TNFi as monotherapy compared with co-therapy with csDMARD, to compare one-year TNFi retention and remission rates, and to explore the impact of peripheral arthritis.

METHODS

Data was collected from 13 European registries. One-year outcomes included TNFi retention and hazard ratios (HR) for discontinuation with 95% confidence intervals (95%CI). Logistic regression was performed with adjusted odds ratios (OR) of achieving remission (ASDAS-CRP < 1.3 and/or BASDAI < 2) and stratified by treatment. Inter-registry heterogeneity was assessed using random-effect meta-analyses, combined results were presented when heterogeneity was not significant. Peripheral arthritis was defined as ≥ 1 swollen joint at baseline (=TNFi start).

RESULTS

Amongst 24 171 axSpA patients, 32% received csDMARD co-therapy (range across countries: 13.5% to 71.2%). The co-therapy group had more baseline peripheral arthritis and higher C-reactive-protein than the monotherapy group. One-year TNFi-retention rates (95%CI): 79% (78-79%) for TNFi monotherapy versus 82% (81-83%) with co-therapy (p< 0.001). Remission was obtained in 20% on monotherapy and 22% on co-therapy (p< 0.001); adjusted OR of 1.16 (1.07-1.25). Remission rates at 12 months were similar in patients with/without peripheral arthritis.

CONCLUSION

This large European study of axial SpA patients showed similar one-year treatment outcomes for TNFi monotherapy and csDMARD co-therapy, although considerable heterogeneity across countries limited the identification of certain subgroups (e.g. peripheral arthritis) that may benefit from co-therapy.

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