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.


Discontinuation of TNF-Inhibitor Treatment in Clinical Practice Has a Negative Impact on Radiographic Progression 2 Years after Initiation of Therapy. Results from the Nationwide Danish DANBIO Registry.

Ornbjerg1,  Lykke M., Ostergaard1,  Mikkel, Boyesen13,  Pernille, Thormann1,  Anja, Tarp6,  Ulrik, Bohme14,  Wolfgang, Dencker14,  Ditte

DANBIO Registry and Depts. of Rheumatology, Copenhagen University Hospitals at Hvidovre and Glostrup, Denmark
Dept. of Rheumatology, Copenhagen University Hospital at Rigshospitalet, Denmark
Dept. of Rheumatology, Copenhagen University Hospital at Slagelse, Denmark
Dept. of Rheumatology, Copenhagen University Hospitals at Hvidovre and Glostrup, Denmark
Dept. of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
Dept. of Rheumatology, Hospital of South West Jutland at Esbjerg, Denmark
Dept. of Rheumatology, King Christian Xth Hospital, Gråsten, Denmark
Dept. of Rheumatology, Odense University Hospital, Denmark
Dept. of Internal Medicine and Rheumatology, Gentofte University Hospital, Denmark
Dept. of Internal Medicine, Copenhagen University Hospital at Holbæk, Denmark
Dept. of Internal Medicine, Hospital Lillebaelt at Vejle, Denmark
Dept. of Rheumatology, Arhus University Hospital at Alborg, Denmark
Dept. of Rheumatology, Arhus University Hospital, Denmark
Dept. of Rheumatology, Copenhagen University Hospital at Frederiksberg, Denmark
Dept. of Rheumatology, Copenhagen University Hospital at Hørsholm, Denmark
Dept. of Rheumatology, Copenhagen University Hospital at Næstved, Denmark

Background:

Randomised controlled trials have shown that tumour necrosis inhibitor (TNF-I) treatment halts erosive progression in rheumatoid arthritis (RA). In clinical practice, patients often withdraw from or switch TNF-I treatment. The impact of discontinuation or change of TNF-I treatment on radiographic progression in RA clinical practice is unknown.

Objectives:

To investigate and compare the annual radiographic progression rates on conventional radiographs (CR) 2 years before and after TNF-I initiation in three subgroups of an observational cohort of RA patients, who

(1) stayed on their first TNF-I,

(2) withdrew from TNF-I treatment or

(3) switched to another TNF-I drug.

Methods:

Conventional radiographs (CR) of hands and wrists were obtained ~2 years before start of TNF-I (time-point A), at the start of TNF-I (B) and ~ 2 years after start of TNF-I (C). Clinical data from the DANBIO registry and the patientfiles were collected. The CRs were scored blinded to chronology (modified Sharp score). Annual radiographic progression rates during DMARD (delta A-B) and TNF-I (delta B-C) treatments were calculated, stratified according to treatment status at timepoint C (Group 1–3, see above). Data were analysed with non-parametric analyses due to a skewed distribution.

Result:

522 patients (76% women, 80% rheumatoid factor positive, age 54(21–86) years (median(range)); disease duration 5 (0–67) yrs) had complete A-B-C series. At time-point B, patients who stayed on TNF-I had a higher rate of concomitant methotrexate (MTX) treatment, while patients who switched TNF-I had a higher DAS28. At time-point A, patients received DMARDs (90%) or no DMARDs (10%). At time-point B, patients started treatment with infliximab (61%), etanercept (15%), or adalimumab (24%). The TNF-I were given in combination with MTX(78%); other DMARDs(10%); or in monotherapy (12%). The duration of Period A-B was median 736 (Interquartile range, IQR 486–1006) days and of period B-C 562 (405–766) days. Patients who withdrew from treatment were treated in 68% (mean) of the follow-up period, and withdrew due to lack of effect (LOE) (46%), adverse events (AE)(37%) or remission (2%), while patients who switched did so due to LOE(68%) and AE(26%), and were treated 99% of the follow-up period.

Radiographic data demonstrated significantly reduced progression rates during TNF-I therapy in all subgroups (Table), and that patients who continued treatment progressed less than patients who stopped.

Timepoint C treatment statusTSS A median (IQR)TSS B median (IQR)TSS C median (IQR)Delta TSS a-b/yr median (IQR)Delta TSS b-c/yr median (IQR)P valuePatients progressing A-B (%)Patients progressing B-C (%)P value
(1) 1st TNF-1 (312 patients)10 (1–34)15 (3–42)15 (3–46)0.64 (0–2.9)0.0 (0–0.5)<0.00013587<0.0022
(2) Withdrawn (60 patients)7 (0–29)11 (2–34)14 (3–34)1.47 (0–2.9)0.0 (0–1.2)0.0007363430.0012
(3) Switched (150 patients)4.5 (0–23)9 (2–34)13 (1–36)0.71 (0–3)0.0 (0–1)<0.000135834<0.00012
P value0.0110.1010.2310.7210.0310.7620.032  
1 Kruskal Wallis2 Chi-square3 Paired Wilcoxon tests

Conclusion:

In this observational study of 522 RA patients, initiation of TNF-I treatment reduced the rate of radiographic progression in the following 2 years, compared to the preceding 2 years of DMARD treatment, irrespective of treatment status after 2 years. The lowest level of radiographic progression was found in patients who continued treatment.

To cite this abstract, please use the following information:
Ornbjerg, Lykke M., Ostergaard, Mikkel, Boyesen, Pernille, Thormann, Anja, Tarp, Ulrik, Bohme, Wolfgang, et al; Discontinuation of TNF-Inhibitor Treatment in Clinical Practice Has a Negative Impact on Radiographic Progression 2 Years after Initiation of Therapy. Results from the Nationwide Danish DANBIO Registry. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :1444
DOI: 10.1002/art.29210

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