Best of 2019 - Are Non-TNF Biologics Superior to TNF inhibitors? Save

Current ACR and EULAR guidelines list TNF-inhibitors (TNFi) abatacept, rituximab, and tocilizumab as being equally effective after methotrexate or as second line therapies when treating rheumatoid arthritis. An analysis from the Swedish Rheumatology Register shows that the non-TNFi biologic DMARDs (bDMARDs), in particular tocilizumab and rituximab, are more effective than TNFi. 

RA patients in this registry were included if they initiated TNFi, rituximab, abatacept or tocilizumab between 2010–2016 as first bDMARD (n = 9333), or after switch from TNFi as first bDMARD (n = 3941).

Effectiveness was assessed 3 and 12 months based on the proportion remaining on therapy and with EULAR Good Response, HAQ improvement >0.2, zero swollen/tender joints and CDAI remission.

At 1 year, patients starting non-TNFi (vs TNFi) as first bDMARD had a higher proportion remaining on drug and reaching most response outcomes as first bDMARD (EULAR Good Response/HAQ improvement):

• TNFi 24.9/25.4%
• Rituximab 28.6/37.2%
• Abatacept 31.9/33.7%
• Tocilizumab 50.9/43.1%).

After switch from a first TNFi, rituximab and tocilizumab, but not abatacept, were associated with significantly better response measures than continuing TNFi (1-year EULAR Good Response/HAQ improvement):

• TNFi 11.6/16.1%
• Rituximab 24.8/33.2%
• Abatacept 13.1/17.5%
• Tocilizumab 34.1/29.4%)

While guidelines are based on metanalyses and expert consensus (and not head-to-head trials), these real world data suggest high efficacy when using non-TNFi bDMARDs, in particular tocilizumab and rituximab, as either the first bDMARD or as a switch candidate after TNFi.