Decision-making by rheumatologists regarding the use of biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in patients with rheumatoid arthritis (RA) was found to be mainly driven by clinical factors, according to results of a study published in Rheumatology and Therapy.

The researchers sought to identify rheumatologist-reported reasons for selection of switching between bDMARDs and tsDMARDs in patients with RA.

A retrospective analysis was conducted using data from the 12th Adelphi Real World Disease Specific Programme for RA. Qualified rheumatologists who were involved in decision-making for 10 or more patients per calendar month completed patient record forms (PRFs). Patients were aged 18 years and older with a rheumatologist-confirmed diagnosis of RA who were receiving b/tsDMARD therapy.

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Rheumatologists were invited to participate in an online, cross-sectional survey, which included their perceptions about treatment/tsDMARDs and the management of patients with RA. The rheumatologists also completed a detailed PRF for the next 12 consecutive patients with RA who received a consultation at their clinic.

A total of 86 rheumatologists completed the survey. Overall, 69% of the rheumatologists were men, managing an average of 87.2 patients with RA per month. All rheumatologists completed the PRFs for approximately 12 patients with RA, which accounted for a total of 1027 PRFs. among these PRFs, 32 were excluded because of the presence of comorbid inflammatory disorders. Ultimately, a total of 621 of the remaining 995 PRFs were included in the current analysis, with an additional 374 patients excluded for not receiving an advanced therapy (b/tsDMARDs) at the time of data collection.

Overall, 73% of the patients were receiving b/tsDMARDs as first-line treatment, 15% as second-line treatment, and 11% as third-line and subsequent-line advanced treatment. The most common first-line b/tsDMARDs were adalimumab, etanercept, and tofacitinib, used by 26%, 24%, and 17% of patients, respectively. Further, the most common second-line b/tsDMARD was abatacept, which was used by 28% of the participants, followed by etanercept and tofacitinib that were each used by 14% of patients. The most common third-line and subsequent-line b/tsDMARD was tofacitinib, which was used by 20% of the participants.

A majority (68%) of the patients received tumor necrosis factor (TNF) inhibitors as first-line b/tsDMARDs. Further, 37% and 39% of patients, respectively, used TNF inhibitors and “other” biologics as second-line treatment. In addition, 48% of patients reported that they used “other” biologics as third-line therapy. Between 21% and 29% of patients were receiving treatment with Janus kinase (JAK) inhibitors across all lines of b/tsDMARDs.

Clinical reasons for selection of a b/tsDMARD, including strong overall efficacy, inhibition of disease progression, maintenance of efficacy over time, reduction in joint stiffness, and low disease activity, across all lines of therapy, were reported by 97% of rheumatologists. This was followed by patient-centric reasons, including the ability to perform everyday tasks/usual activities, sustained pain relief, and improvement/ maintenance of quality of life, which were reported by 68% to 76% of rheumatologists as the second most common reason for selecting a b/tsDMARD.

A total of 163 patients (26.2%) switched from a first-line to a second-line b/tsDMARD. Among these individuals, 44%, 28%, and 17% had switched from a TNF inhibitor to another, from a TNF inhibitor to a non-TNF biologic, and from a TNF inhibitor to a JAK inhibitor, respectively. Patients cited lack of efficacy and worsening of disease as the most common reasons for switching biologic agents.

Limitations of the analysis included potential rheumatologist selection bias, the fact that patient samples collected were not randomized, and that the quality of data was dependent on accurate reporting by rheumatologists.

Based on findings from the survey, the researchers concluded, “TNF [inhibitors] remain the most prescribed b/tsDMARD for first-line and second-line treatments. Strong overall efficacy was the primary reason for selecting therapy and loss of efficacy was the primary reason for switching therapy.”

Disclosure: This research was supported by Immunex, a subsidiary of Amgen, Inc. Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures. 


Holdsworth EA, Donaghy B, Fox KM, Desai P, Collier DH, Furst DE. Biologic and targeted synthetic DMARD utilization in the United States: Adelphi Real World Disease Specific Programme for rheumatoid arthritis. Rheumatol Ther. Published online September 2, 2021. doi:10.1007/s40744-021-00357-1