Here’s what will change my practice in Rheumatoid Arthritis Save

Here's what I learned at ACR23 that will change the way I practice in rheumatoid arthritis. 

Which is better in active RA after failure of csDMARDs, a TNFi or a JAKi?

Baricitinib was compared to Adalimumab in a pragmatic trial (Abstract 0450). There were approximately 100 patients per arm. Although Baricitinib 4mg daily may have had some slightly deeper responses, the two were not different (statistically non inferiority was met). So your decision to use one class of drugs or another as first advanced therapy after failure of MTX and/or other csDMARDs will likely depend on:

Comfort of prescriber – safety, benefit

Patient – wishes, preference (oral, injectable, etc), perceived safety

System factors – access, cost of drug, cost to the patient for their copayment, country guidelines/warnings

Is one drug more friendly than another for RA patients with ILD?

No!

Data from the VA over several years were used as an emulation trial to determine in RA-ILD the respiratory hospitalizations or deaths comparing TNFi to nonTNFi advanced therapies (other bDMARDs and JAKi). Patients (237 per group) were matched (propensity scoring) and no differences were seen between the two groups (abstract 1582).

There could be confounding (channeling bias in what was prescribed), but overall, neither group had major outcome differences. The breakdown of various drugs in the nonTNFi group would have been helpful but the numbers would have been small and JAKi were not widely available or used in this group until more recently compared to bDMARDs which may have also biased the results if different drug groups analyses were performed.

My take homes:

Treat to a target and get your csDMARD-IR patient adequately treated with whatever drug class you choose.

Treat active RA which is a risk factor for development of and progression of RA-ILD and which treatment with advanced therapies may not matter, just do it to get the patient into remission where possible!