title: Factors influencing the choice of first- and second-line biologic therapy for the treatment of rheumatoid arthritis: real-life data from the Italian LORHEN Registry.
abstract: According to international recommendations, the selection of the biologic disease modifying anti-rheumatic drug (bDMARD) for rheumatoid arthritis (RA) is mainly left to the clinician's preference. We analyzed the real-life factors influencing the first-line choice or the switching strategy, focusing on the prescription of abatacept (ABA) or tocilizumab (TCZ) compared to TNFα inhibitors (TNFi). Patients enrolled in the Lombardy Rheumatology Network (LORHEN) Registry after January 1, 2010, when all considered bDMARD agents were available, were included. The population was divided into "first-" and "second-line" bDMARD. We included 1910 patients (first line n = 1264, second line n = 646). Age was higher in ABA or TCZ vs TNFi treated patients (p < 0.0001). Positive latent tuberculosis screening was associated with first-line ABA (p = 0.002). Methotrexate (MTX) combination therapy was lower in the TCZ group (p = 0.02). The type (dyslipidemia, hypertension, pulmonary disease) and the number of comorbidities influenced the choice towards ABA (p = 0.01). Multinomial logistic regression demonstrated that a second-line treatment, higher age, dyslipidemia, pulmonary disease, other comorbidities, and extra-articular RA manifestations were associated with ABA compared to TNFi. TCZ was associated with a second-line treatment, higher age, and more severe disease activity. Stopping the first bDMARD due to adverse events (AE) influenced the choice towards ABA. In real life, higher age and comorbidities influence the choice towards ABA and TCZ compared to TNFi. ABA was preferred in case of suspension of previous treatments due to AE. After failing a first-line TNFi, swapping to a different mechanism of action is more common.
authors.affiliation: Department of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Viale Golgi 19, 27100, Pavia, Italy. sara.saramonti@gmail.com.
authors.forename: Sara
authors.initials: S
authors.lastname: Monti
authors.affiliation: Biometry and Clinical Epidemiology, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy.
authors.forename: Catherine
authors.initials: C
authors.lastname: Klersy
authors.affiliation: Reumatologia, Spedali Civili, Brescia, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Gorla
authors.affiliation: University Hospital L Sacco, Milan, Italy.
authors.forename: Piercarlo
authors.initials: P
authors.lastname: Sarzi-Puttini
authors.affiliation: University Hospital L Sacco, Milan, Italy.
authors.forename: Fabiola
authors.initials: F
authors.lastname: Atzeni
authors.affiliation: Ospedale Mauriziano, Turin, Italy.
authors.forename: Raffaele
authors.initials: R
authors.lastname: Pellerito
authors.affiliation: Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy.
authors.forename: Enrico
authors.initials: E
authors.lastname: Fusaro
authors.affiliation: Santa Chiara Hospital, Trento, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Paolazzi
authors.affiliation: Struttura di Reumatologia A.S.O. "SS. Antonio e Biagio e C. Arrigo", Alessandria, Italy.
authors.forename: Pier Andrea
authors.initials: PA
authors.lastname: Rocchetta
authors.affiliation: Department of Rheumatology, Gaetano Pini Institute, Milan, Italy.
authors.forename: Ennio Giulio
authors.initials: EG
authors.lastname: Favalli
authors.affiliation: Department of Rheumatology, Gaetano Pini Institute, Milan, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Marchesoni
authors.affiliation: Department of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Viale Golgi 19, 27100, Pavia, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Caporali
mesh_terms: D000069594:Abatacept / Q000627:therapeutic use; D000368:Aged; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D001691:Biological Therapy / Q000009:adverse effects / Q000379:methods*; D015897:Comorbidity; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007558:Italy; D016015:Logistic Models; D008297:Male; D008727:Methotrexate / Q000627:therapeutic use; D008875:Middle Aged; D012042:Registries; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors / Q000627:therapeutic use
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha; D000069594:Abatacept; C502936:tocilizumab; D008727:Methotrexate
keywords: Abatacept; Biologic therapy; Rheumatoid arthritis; TNF inhibitors; Tocilizumab; Treatment choice