After failure of rituximab therapy, patients who receive abatacept therapy are more likely to have a higher drug retention rate compared with patients receiving tumor necrosis factor inhibitor (TNFi) therapy, according to research published in Joint Bone Spine.

Researchers conducted a retrospective, multicenter study of adult patients with rheumatoid arthritis (RA) to assess which factors influence a patient’s choice of biologic disease-modifying antirheumatic drug (bDMARD) after rituximab failure. The study included 152 patients who received at least 1 rituximab dose, then started a new bDMARD (tocilizumab, TNFi, or abatacept) within 1 year of rituximab therapy.

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The study cohort was 77% women, with a mean age of 57±13 years. The median disease duration was 14.3 years (interquartile range [IQR] 7.8-19.8). The majority of patients in the cohort were rheumatoid factor positive or anticyclic citrullinated peptide positive (67% and 70%, respectively). Patient’s median time from the last rituximab dose to first bDMARD dose was 6 months (IQR 4-7).

In terms of bDMARD therapies, 37.5% of patients received tocilizumab, 30.9% received a TNFi, and 31.6% received abatacept. Due to inefficacy, 129 patients stopped rituximab therapy; among these patients, 51, 41, and 37 received tocilizumab, TNFi, or abatacept, respectively, and 44 patients stopped rituximab due to serious infection. Within that group, 17, 12, and 15 patients received tocilizumab, TNFi, or abatacept, respectively.

Investigators conducted multidimensional factorial analyses to assess the relationship between factors associated with different treatment groups. Profiles of patients receiving abatacept differed from profiles of patients receiving either tocilizumab or TNFi: patients who received abatacept were older men, more likely to smoke or drink alcohol, and had more instances of cardiac or respiratory diseases and extra-articular RA manifestations.

The disease activity score in 28-joint Disease Activity Score erythrocyte sedimentation rate (ESR) was lower in tocilizumab-treated patients at 3, 6, and 12 months compared with patients treated with TNFi or abatacept. Researchers attribute this difference primarily to a rapid decrease in ESR in patients treated with tocilizumab (mean ESR at 2, 6, and 12 months 4.8±5.8 mm/h, 8.4±17.1 mm/h, and 8.8±12.7 mm/h, respectively).

At 3 months, 90 patients were able to have their European League Against Rheumatism response evaluated. A good or moderate response was noted in 64.4% of these patients. At 6 and 12 months, data were available for 68 and 60 patients, with 72% and 73%, respectively, demonstrating a good or moderate response rate.

Researchers conducted a multivariate analysis following adjustment of propensity score, disease duration, and concomitant glucocorticoid and DMARD use. No differences among the 3 groups were noted. In a univariate analysis, investigators found that the drug retention rate was significantly higher in the abatacept group compared with the TNFi group.

Limitations to the study included the retrospective design of the study, as well as the possibility of missing data for some variables.

“Following [rituximab] discontinuation, the drug retention rate remained higher with [abatacept] than with TNFi even after adjusting for propensity score,” the researchers concluded. “Our results must be confirmed using prospective randomized studies to evaluate definitively the best treatment sequence.”  

Reference

Vial G, De Pouilly A, Scouppe L, et al. Factors influencing the choice of biologic therapy following rituximab in patients with rheumatoid arthritis: a retrospective study using propensity score [published online July 29, 2019]. Joint Bone Spine. doi: 10.1016/j.jpsin.2019.07.008