Arthritis & Rheumatism, Volume 63,
November 2011 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Chicago, Illinois November 4-9, 2011.

Efficacy of TNF Switch After Failure of One TNF Inhibitor Results From a Nation-Wide Observational Study.

Chatzidionysiou1,  Katerina, Eriksson2,  Jonas, Askling3,  Johan, van Vollenhoven1,  Ronald F.

Karolinska Institute, Stockholm, Sweden
Clinical Epidemiology Unit, Dept of Medicine, Karolinska Institutet, Stockholm, Sweden
Clinical Epidemiology Unit, Dept of Medicine, Karolinska Institutet, Solna, Sweden


The purpose of this study was to determine whether patients who failed one anti-TNF benefit from switching to another anti-TNF and whether the specific order of agents and reason for switch is significant.


Data from the ARTIS registry were used. Patients with RA, who received an anti-TNF [etanercept (ETA), adalimumab (ADA) or infliximab (INF)] as first biologic and subsequently switched to an alternative anti-TNF, were included in the analysis. Treatment segments were analysed according to DAS28 and HAQ reduction and EULAR response at 6 months after baseline. Treatment results were analysed for each biologic, by type of previous anti-TNF and reason for discontinuation (primary and secondary inefficacy or intolerance). Multiple treatment segments with the same anti-TNF were disregarded for this analysis.


A total of 1080 patients were included. Of these, 520 switched to ETA, 466 to ADA, and 94 to INF. Complete data were available for appr. 50% of patients and were evenly distributed between groups. At baseline (BL= start of 2nd anti-TNF) no differences in age, sex, disease duration, RF, HAQ and concomitant NSAIDs were observed between groups. BL DAS28 (mean±SD) was significantly lower for ADA (4.79±1.32) than ETA (5.15±1.32, p<0.0001) and INF (5.13±1.22, p=0.04). INF was more often combined with DMARDs (81.9%) than ETA (69.3%, p=0.007) and ADA (65.7%, p=0.001), but less often with glucocorticoids (39.4%) than ETA (51.2%, p=0.02) and ADA (50.6%, p=0.03).

Significant clinical improvements were observed for the whole cohort of patients. DAS28 improvement at 6 months was 1.59±1.47 for ETA, 1.17±1.35 for INF and 1.00±1.32 for ADA (p=0.002 ETA vs. ADA, p=0.29 ETA vs. INF; p values adjusted for age, sex, BL DAS28, conc. DMARDs and glucocorticoids). HAQ improvement at 6 months = 0.26±0.52 for ETA, 0.14±0.50 for INF and 0.14±0.43 for ADA (adjusted p=0.42 ETA vs. INF, p=0.23 ETA vs. ADA). The percentages of EULAR Good/Moderate/Non-responders were 28/43/29% for ETA, 21/46/33% for INF and 17/45/38% for ADA (p=0.02 between groups). In table 1 the effectiveness of each anti-TNF by type and reason for discontinuation of the previous anti-TNF is summarized.

Table 1. Efficacy of the 2nd antiTNF assessed by DAS28 (mean±SD) and HAQ (mean±SD), reductions at 6 months from baseline, accordning to the type of previous antiTNF and reason for discontinuation. ([Number of patients])

1st antiTNF2nd antiTNFDeltaDAS28 6mDeltaHAQ 6m
ETAADA0.93 ± 1.21 [154]0.340.12 ± 0.43 [164]0.70
 INF1.24 ± 1.40 [36] 0.18 ± 0.44 [36] 
ADAETA1.39 ± 1.46 [121]0.880.25 ± 0.44 [127]0.25
 INF0.91 ± 1.16 [10] -0.02 ± 0.67 [10] 
INFETA1.75 ± 1.47 [145]0.300.26 ± 0.57 [145]0.82
 ADA1.16 ± 1.56 [63] 0.19 ± 0.43 [68] 
Reason discontinuation 1st antiTNF     
IntoleranceETA1.68 ± 1.47 [62]0.850.30 ± 0.46 [61]0.17
 INF1.32 ± 0.90 [6] 0.20 ± 0.11 [5] 
 ADA1.24 ± 1.79 [46] 0.06 ± 0.42 [53] 
Primary inefficacyETA1.56 ± 1.45 [82]0.130.25 ± 0.58 [87]0.86
 INF1.23 ± 1.33 [17] 0.13 ± 0.66 [19] 
 ADA1.02 ± 1.03 [63] 0.16 ± 0.40 [65] 
Secondary inefficacyETA1.65 ± 1.41 [83]0.02**0.25 ± 0.48 [86]0.92
 INF1.04 ± 1.11 [12] 0.14 ± 0.50 [10] 
 ADA0.99 ± 1.16 [59] 0.20 ± 0.45 [62] 
* Adjusted for BL age, sex, DAS28, conc. DMARDs and glucocorticoids.
** ETA vs. ADA p=0.005


In this large observational cohort, patients who failed anti-TNF therapy do benefit from switching to other TNF inhibitors. ETA as 2nd anti-TNF yielded significantly greater DAS28 reductions than INF and ADA, but due to the relatively large number of incomplete data this finding must be interpreted with caution. For patients who discontinued anti-TNF because of secondary inefficacy, switching to ETA appeared more effective than switching to ADA.

To cite this abstract, please use the following information:
Chatzidionysiou, Katerina, Eriksson, Jonas, Askling, Johan, van Vollenhoven, Ronald F.; Efficacy of TNF Switch After Failure of One TNF Inhibitor Results From a Nation-Wide Observational Study. [abstract]. Arthritis Rheum 2011;63 Suppl 10 :2240

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