Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.

Real Life Analysis of the Romanian Experience in Switching from Anti-TNF Based Therapy to Rituximab.

Ancuta1,  Ioan, Codreanu2,  Catalin, Ionescu4,  Ruxandra Maria, Bolosiu5,  Horatiu, Parvu3,  Magda, Georgescu6,  Lia

"Dr. I. Cantacuzino" Hospital, Bucharest, Romania
"Dr. I. Stoia" Center for Rheumatic Diseases, Bucharest, Romania
"N. Gh. Lupu" Clinical Hospital, Bucharest, Romania
"Sfanta Maria" Clinical Hospital, Bucharest, Romania
Rheumatology Clinic, Cluj - Napoca, Romania
Rheumatology Clinic, Tirgu-Mures, Targu - Mures, Romania


The rheumatoid arthritis is a chronic disorder affecting physical function and patient's quality of life, and its treatment carries therefore important costs for the National Health Insurance House (NHIH). In case of an inadequate response with the first anti-TNF medication, a largely used option is currently to continue the treatment with drugs from the same class, either by modifying dosage/frequency of the initial ones, or by prescribing different anti-TNF. Using the available data from NHIH, we researched if continuing with a second anti-TNF brings both the expected benefits for the patients and is reasonably cost effective for NHIH, versus switching to rituximab (RTX) after the initial medication, instead of using again anti-TNF drugs.

Methods, Materials and Analytical Procedures Used:

The analysis was performed for 200 patients (78% women with an average age of 55 and 22% men, average age 54) who were all prescribed in the first stage anti-TNF alpha medication. In the second stage, 102 patients were treated with RTX for 3 courses (after one anti-TNF-IR), while 98 of them received a 2nd anti-TNF medication and after an inadequate response to that were treated with 3 courses of RTX. The median time for follow-up was 1.5 years for each arm. We evaluated the effectiveness of the 2 treatment approaches by calculating the D between DAS28 measured after and before each stage of the therapy. The financial efficiency was computed as ratio of average cost per DAS28 point for each strategy.

Summary of the Results:

Patients had a good response to the first anti-TNF alpha medication, the medium duration of the treatment being 2.43 years. Average DAS28 before treatment was found 6.43, and 3.88 after (medium DDAS28 =-2.55). For the 98 patients having a second anti-TNF alpha therapy we noticed an increase of DAS28, the medium DDAS28 reaching 0.96, evidencing development of resistance to the anti-TNF medication. For the 102 patients that switched to RTX in the second treatment stage, DAS28 decreased, reaching DDAS28 =-2.39. Over the 3 RTX cycles, DAS28 decreased consistently for all patients but reached its lowest value for the patients having RTX after the first anti-TNF, (DDAS28 =-3.9).


Repeating anti-TNF alpha medication after an initial a-TNF inadequate response did not bring benefits to the patients, as DAS28 increased during the second stage of the treatment. The incomplete immunosuppression caused by the first anti-TNF medication could lead to development of resistance to treatment which becomes significant during the next stage. Introducing RTX right after the first anti-TNF inadequate response proved to be the most effective option, leading to cumulating of clinical benefits and to consolidation of lower DAS28 response with each following RTX cure. This strategy is also more efficient, as the cost per DAS28 point decreased compared with introducing RTX only after the second anti-TNF. Therefore the balance cost-benefits is clearly in favor of initiating a RTX medication immediately after the first anti-TNF therapy and this shall be our recommendation for NHIH.

To cite this abstract, please use the following information:
Ancuta, Ioan, Codreanu, Catalin, Ionescu, Ruxandra Maria, Bolosiu, Horatiu, Parvu, Magda, Georgescu, Lia; Real Life Analysis of the Romanian Experience in Switching from Anti-TNF Based Therapy to Rituximab. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :405
DOI: 10.1002/art.28174

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