OBJECTIVES

The American College of Rheumatology recommends initiating rheumatoid arthritis (RA) treatment with a conventional synthetic disease-modifying antirheumatic drug (csDMARD) and escalating to csDMARD combination therapy or targeted immunomodulators in cases of treatment failure. We examined real-world treatment patterns among RA patients initiating first DMARD.

METHODS

From a large US health claims database, we selected adults with ≥2 RA claims ≥30 days apart initiating their first DMARD (index date [ID]; 1/1/2012–3/31/2017). All patients had continuous enrollment 1 year pre- and >1 year post-ID. We mapped treatment patterns sequentially up to six regimens.

RESULTS

Among first-DMARD initiators (N=28,201, median age 54 years, median follow-up 28 months) 89.0% began on csDMARD (84% monotherapy, 5% combination therapy). After initiating first DMARD, 19.6% persisted on initial regimen, 23.4% discontinued DMARD completely, and 57.1% switched regimens: 23.9% csDMARD, 12.1% csDMARD+csDMARD(s), 12.0% tumor necrosis factor-α inhibitor (TNFi)+csDMARD, 6.1% TNFi, 3.0% other treatments. After initiating second regimen, 20.2% persisted on second regimen, 11.2% discontinued DMARD, and 25.6% switched regimen: 8.1% csDMARD, 7.5% TNFi+csDMARD, 3.6% TNFi, 3.5% csDMARD+csDMARD(s). Each subsequent treatment contributed diminishing increments to attaining persistency. During follow-up, patients experienced at least three (25.6%), four (10.9%), five (4.6%), and six (2.0%) regimens. By end of follow-up, a total of 57.2% patients persisted on a prior regimen and 40.8% patients discontinued all DMARDs. Some patients cycled within treatment class (e.g., from csDMARD to csDMARD or TNFi to TNFi), including multiple monotherapy regimens.

CONCLUSIONS

Real-world RA treatment patterns revealed existing unmet needs, indicated by multiple treatment cycles, low persistency, and prevalent DMARD discontinuations. During the >2-year follow-up, approximately 50% reached persistency on a DMARD regimen, indicating an ongoing need for treatment options. DMARD discontinuations (40.8%) deviates from treatment guidelines and US quality metrics, which advise continued DMARD treatment. Repeated within-class cycling indicates discordance with recommendations on treatment advancement.

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