When TNF Inhibitor Fails in RA: Cycle or Swap?

Meroni PL, Favalli EG, Biggioggero M, Marchesoni A. Survival on treatment with second-line biologic therapy: a cohort study comparing cycling and swap strategies. Rheumatology. (2014) doi: 10.1093/rheumatology/keu158  [First published online: April 12, 2014]

Tumor necrosis factor inhibitors (TNFis) fail around 30% of rheumatoid arthritis (RA) patients, or are discontinued for various reasons. What works best as the next option? The first study to test the question suggests swapping for a biologic with a different mechanism of action, rather than switching to a different TNFi.

The retrospective study involved 201 RA patients treated with biologics since 1999 who had discontinued their first-line TNFi and started a second-line biological therapy. Regardless of the reason for stopping the original drug, patients did just as well on a drug that does not target TNF as on a different TNF inhibitor, and were less likely to discontinue a drug with a different mode of action.

Among the cohort, 119 patients were switched to a second TNFi (the cycling group) -- 67 to etanercept (56.3%), 31 to adalimumab (26.1%) and the rest to infliximab, certolizumab pegol, or golimumab.

Of the 82 patients who exchanged a TNFi for a drug with a different target (the swap group), almost half were took rituximab (n=40, 48.8%), about a third started abatacept (n=26,31.7%) and the rest took tocilizumab (n = 15, 18.3%).

There were no significant differences in the treatment retention rates between different drugs in the swap group. However, the adjusted risk of discontinuation was slightly greater among patients who stopped their first TNFi due to safety issues or inefficacy.

The swap group had higher disease activity scores than the cycling group, but these differences became non-significant after adjusting for other factors.