Impact of adverse drug reactions on the treatment pathways of early rheumatoid arthritis patients: a prospective observational cohort study

BACKGROUND

Several patient characteristics may be of influence on treatment pathways of rheumatoid arthritis (RA) patients in clinical practice. The aim of this study is to analyze treatment pathways of early RA patients stratified for gender and adverse drug reaction (ADR) occurrence.

RESEARCH DESIGN AND METHODS

Treatment pathways of patients included in the DREAM-RA treat-to-target cohort I between 16th of July 2006-30th of April 2020 were assessed. Treatment pathways were visualized in Sankey diagrams. Follow-up time, duration per treatment and the number of treatments received were stratified for gender and ADR occurrence and analyzed. Independent t-tests and chi-square tests were performed where applicable.

RESULTS

Treatment pathways of 372 patients (follow-up: 2488.4 years, mean 6.7 ± 3.7 years) were analyzed. The Sankey diagrams visualize that treatment pathways became increasingly varied and complex over time. No significant differences were found when comparing female patients and male patients. However, the average treatment duration was shorter in patients with ADRs (1.8 vs. 2.7 years, p < 0.05), and the number of treatments higher (3.5 vs. 2.5, p < 0.05).

CONCLUSIONS

Treatment pathways increase in complexity over time. Differences were found between patients with and without ADRs, with patients that experience ADRs receiving more and shorter treatments.

First-time adverse drug reactions, survival analysis, and the share of adverse drug reactions in treatment discontinuation in real-world rheumatoid arthritis patients: a comparison of first-time treatment with adalimumab and etanercept

BACKGROUND

This study aims to compare nature and frequency of adverse drug reactions (ADRs), time to first ADR, drug survival, and the share of ADRs in treatment discontinuation of first-time treatment with adalimumab (ADA) and etanercept (ETN) in real-world RA patients.

RESEARCH DESIGN AND METHODS

Retrospective, single-center cohort study including naïve patients treated between January 2003-April 2020. Time to first ADR and drug survival of first-time treatment were studied using Kaplan-Meier and Cox-regression models up to 10 years, with 2- and 5-year post-hoc sensitivity analysis. Nature and frequencies of first-time ADRs and causes of treatment discontinuation were assessed.

RESULTS

In total, 416 patients (ADA: 255, ETN: 161, 4865 patient years) were included, of which 92 (22.1%) experienced ADR(s) (ADA: 59, 23.1%; ETN: 33, 20.4%). Adjusted for age, gender and concomitant conventional DMARD use, ADA was more likely to be discontinued than ETN up to 2-, 5- and 10-year follow-up (adjusted HRs 1.63; 1.62; 1.59 (all p<0.001)). ADRs were the second reason of treatment discontinuation (ADA 20.7%, ETN 21.4%).

CONCLUSIONS

Despite seemingly different nature and frequencies, ADRs are the second reason of treatment discontinuation for both bDMARDs. Furthermore, 2-, 5-, and 10-year drug survival is longer for ETN compared to ADA.

POS0651 IMPACT OF ADVERSE DRUG REACTIONS ON THE TREATMENT PATHWAYS OF EARLY RHEUMATOID ARTHRITIS PATIENTS

Background

Rheumatoid arthritis (RA) patients frequently pass through several medications in order to achieve and maintain acceptable disease control The clinical heterogeneity and variable course of the disease, plus the availability of multiple classes and subclasses of DMARDs may lead to very different and complex treatment sequencing in individual patients. Limited real-world data exists regarding treatment pathways among patients with RA. Adverse drug reactions (ADRs) belong to the stop reasons of medication, but the impact of ADRs on treatment pathways has not been quantified.

Objectives

To assess differences in treatment pathways between RA patients with and without adverse drug reactions (ADRs).

Methods

Single center retrospective observational study, using real-world data collected in the Dutch Rheumatoid Arthritis Monitoring (DREAM-RA) registry from Medisch Spectrum Twente (Enschede, the Netherlands). From all early RA patients enrolled between 16 July 2006 and 30 April 2020, the first four consecutive courses of treatment were assessed. Patients were selected from the DREAM early RA treat-to-target cohort I.1 The use of corticosteroids per protocol was allowed but not considered as a DMARD treatment. Any alteration in (a combination of) medication was viewed as a separate treatment, and thus any addition, subtraction or change in medication was the start of a new treatment. If a patient was without continuous treatment for 90 days or more in between treatments, this was considered a temporary stop of treatment. Treatment pathways were stratified for occurrence of at least one ‘ADR or ‘No ADR’. Differences in duration of treatment, number of treatments, and the proportion of treatments with csDMARDs, bDMARDs and a combination of csDMARDs and bDMARDs between patients with and without ADRs are assessed.

Results

Treatment pathways of 372 RA patients (66.1% females) were assessed (Table 1). The average duration of treatment was shorter in patients that experienced at least one ADR (1.8 vs. 2.7 years, p<0.001), and the number of treatments was higher (3.5 vs. 2.5, p<0.001), than in those that experienced no ADR. Furthermore, there was a difference between these groups in the proportion of treatments with csDMARD(s), bDMARD(s) or a combination of the two (p<0.001). This was for the ‘No ADR’ group respectively 93%; 1%; 6%, and for the ‘ADR’ group respectively: 77%; 8%; 15%.

Table 1.

Characteristics of patient with and without adverse drug reactions (ADRs) and treatment pathways

All patientsFemalesMalesPatients without ADRsPatients with ADRsTotal, n (% of all patients)372 (100.0)246 (66.1)126 (33.8)285 (76.6)87 (23.3)Female, n (% of total)246 (66.1)N/AN/A183 (64.2)63 (72.4)Age at start of treatment in years, mean ±SD57.8 ±14.057.3 ±14.359.0 ±13.258.4 ±14.456.0 ±12.3Follow-up time in years, mean ±SD6.7 ±3.76.8 ±3.66.6 ±3.96.9 ±3.86.2 ±3.4Duration per treatment in years, mean ±SD2.4 ±2.92.4 ±2.82.4 ±2.92.7 ±3.01.8 ±2.2*Distribution of treatments:1113 (30.4)72 (29.3)41 (32.5)104 (36.5)8 (9.2)225 (6.7)18 (7.3)7 (5.6)20 (7.0)5 (5.8)number of patients that received 1, 2, 3 or 4 treatments, n (%)383 (22.3)53 (21.5)30 (23.8)70 (24.6)13 (14.9)*4 or more151 (40.6)103 (41.9)48 (38.0)91 (31.9)61 (70.1)Number of treatments, mean ±SD2.7 ±1.32.8 ±1.32.7 ±1.32.5 ±1.33.5 ±1.0*Number of patients stopped with treatment, n (% of total)84 (22.6)56 (22.8)28 (22.2)71 (24.9)18 (20.7)

* p<0.001

Conclusion

Treatment pathways for patients with and without ADRs differ significantly. Patients that experience ADRs have shorter duration of treatments and have more consecutive treatments utilizing more bDMARDs.

References

[1]Steunebrink LM, Versteeg GA, Vonkeman HE, et al. Initial combination therapy versus step-up therapy in treatment to the target of remission in daily clinical practice in early rheumatoid arthritis patients: results from the DREAM registry. Arthritis Res Ther 2016;18:60.

Disclosure of Interests

Fenna Poppelaars: None declared, Jurriaan Jansen: None declared, Peter ten Klooster: None declared, Tristan Coppes: None declared, Kimberly Velthuis: None declared, Harald Vonkeman Speakers bureau: Amgen, BMS, Celgene, Galapagos, GSK, Janssen-Cilag, Lilly, Novartis, Pfizer, Roche, Sanofi-Genzyme, UCB, Grant/research support from: Abbvie, Sanofi-Genzyme, Naomi Jessurun: None declared

POS0620 TREATMENT PATHWAYS OF RHEUMATOID ARTHRITIS PATIENTS LEADING TO BIOLOGIC THERAPY VISUALIZED IN A SANKEY DIAGRAM

Background:

Treatment of rheumatoid arthritis (RA) has changed in the past 20 years due to the arrival of biologic disease-modifying antirheumatic drugs (bDMARDs) and the application of treat to target strategies. Many different combinations of conventional synthetic (cs)DMARDS and bDMARDS are being applied in daily practice. It is difficult to visualize and understand all the different treatment pathways that are sequentially being used over longer periods of time in a real-world setting. We therefore investigated whether a Sankey diagram is a suitable tool to study and visualize which treatment pathways exist and to what extent a RA treatment protocol is being followed.

Objectives:

To illustrate the treatment pathways over longer periods of time in a cohort of early RA patients and to assess adherence to the treatment protocol using Sankey diagrams.

Methods:

This single-centre retrospective, observational cohort study used data from the DREAM-RA registry. Patients were treated according to a treat to target strategy with a step-up DMARD treatment protocol when remission was not achieved, initial steps were starting with MTX 15 mg/wk, week 8 MTX 25 mg/wk, week 12 MTX+SSZ 2dd1000mg, week 20 MTX+SSZ 3dd1000mg, week 24 MTX+adalimumab 40mg/2wk, week 36 MTX+adalimumab 40mg/wk. Although the protocol met full consensus, adherence to the protocol in individual patients was at the discretion of the treating rheumatologist. In this study, patients were included if they received a continuous treatment with a conventional synthetic or biologic DMARD between 1 January 2002 and 30 April 2020. During treatment, corticosteroids per protocol were allowed but not considered as an individual treatment. Evaluated outcomes included: the consecutive treatments that patients followed including start- and stop-date of treatments, the proportion of patients that received bDMARDs, the number of switches until first bDMARD, and time to first bDMARD. Furthermore, the lower limit of adherence to the protocol was estimated by considering all patients (% of total) treated according to the protocol. This information was determined by verifying whether the patient was being treated according to the protocol after each switch.

Results:

A total of 372 patients were included in this study (Table 1). The mean overall follow-up time of the cohort was 8.83 (± 3.59) years. The follow-up time for the first 4 treatments, depicted in the Sankey diagram was 6.28 (± 3.31) years. At least 45 (12%) patients started with a bDMARD before all previous protocol steps were followed. At the start of treatment, 81% of the patients were treated according to the protocol, this was reduced to 28% after one switch. The lower limit of adherence to the predefined protocol after 3 switches were roughly 5% of all patients.

Table 1.

Absolute counts of T-cell subpopulations at baseline, after 6 and 12 m of TCZ therapy

All patients(n=372)Gender, female, n (%)246 (66.1)Age, year, mean ± SD67.9 ± 13.61Overall follow-up, years ± SD8.83 ± 3.59Follow-up first 4 treatments, years ± SD6.28 ± 3.31Baseline DAS-28 score, mean ± SD3.60 ± 1.41Rheumatoid factor positive, n (%)336 (90.3)Patients who eventually received a bDMARD, n (%)108 (29.0)Number of switches until first bDMARD, mean ± SD2.7 ± 1.41Time to first bDMARD, years ± SD3.66 ± 3.00Figure 1.

Sankey diagram of the treatment pathway of the first 3 switches of RA patients. The average duration of treatment of a flow is displayed in years if the flow included more than 20 patients. (MTX= methotrexate; SSZ= sulfasalazine; HCQ = hydroxychloroquine; LEF= leflunomide; bDMARD= monotherapy bDMARD; Combi csDMARDs= combination therapy of csDMARDS; csDMARD(s)+bDMARD= combination therapy of one or two csDMARD(s) + a bDMARD; No therapy= no treatment received >3 months; Other = medication that is not a (cs)(b)DMARD)

Conclusion:

Sankey diagramming can be used to illustrate complex real-world treatment data of a treat to target cohort of RA patients. Treatment protocol adherence can be assessed with the help of a Sankey diagram. After 3 switches, the lower limit of adherence to the protocol was roughly 5%.

Disclosure of Interests:

Tristan Coppes: None declared, Naomi Jessurun: None declared, Jurriaan Jansen: None declared, Kimberly Velthuis: None declared, Peter ten Klooster: None declared, Harald Vonkeman Consultant of: BMS, Celgene, Celltrion, Galapagos, Gilead, Janssen-Cilag, Lilly, Novartis, Pfizer, Sanofi-Genzyme, Grant/research support from: Abbvie

AB0196 SURVIVAL ANALYSIS OF TIME TO FIRST ADVERSE DRUG REACTION AND DRUG SURVIVAL IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH ADALIMUMAB AND ETANERCEPT

Background:

Treatment of rheumatoid arthritis (RA) with biologic disease-modifying antirheumatic drugs (bDMARDs) has been common practice in the last two decades. However, differences in patients experiencing adverse drug reactions (ADRs) between individual bDMARDs, such as adalimumab (ADA) and etanercept (ETN), during first time treatment has not been studied yet in real-world settings.

Objectives:

To compare proportions of RA patients experiencing ADRs as well as survival to first ADR and drug survival during treatment with ADA and ETN.

Methods:

Retrospective single centre cohort study including adult patients with RA, treated with either ADA or ETN between 1 January 2003 and 30 April 2020. The proportions of patients experiencing an ADR were compared by assessing the percentage of patients, treated with either ADA or ETN, experiencing at least one ADR during their first time treatment. Survival to first ADR and drug survival were assessed by calculating time between start of treatment and first ADR and start of treatment and discontinuation of treatment respectively. Stop and restart of treatment within 90 days was considered as continuous use. Differences in proportions were statistically tested using Fisher’s Exact Test. Differences in drug survival between ADA and ETN were tested by Kaplan-Meier analysis and Log Rank tests.

Results:

A total of 422 patients were included in this study (ADA 259, ETN 163). For 93 patients (21.2%) an ADR was registered during first time treatment. The proportion of patients experiencing at least one ADR during their first time treatment was 22.7% for ADA and 20.2% for ETN (p=0.628). Survival time to first ADR did not differ significantly between ADA and ETN (median survival ADA 10.34 years (95% CI [7.62-13.06], median survival ETN not reached, p=0.109, figure 1A). Median drug survival was 1.75 years for ADA (95 CI [1.38-2.11]) and 2.68 years for ETN (95% CI [1.73-3.64]). Drug survival differed significantly (p<0.001, figure 1B).

Figure 1.

Kaplan-Meier survival curves for adalimumab and etanercept with (a) survival to first ADR and (b) drug survival.

Conclusion:

Neither the proportion of patients experiencing ADRs nor survival to first ADR during first time treatment with ADA and ETN differed significantly. Drug survival of first time drug treatment of ADA was significantly lower compared to drug survival of first time drug treatment of ETN.

Disclosure of Interests:

My Nguyen: None declared, Kimberly Velthuis: None declared, Joep Scholl: None declared, Jurriaan Jansen: None declared, Leanne Kosse: None declared, Peter ten Klooster: None declared, Naomi Jessurun: None declared, Harald Vonkeman Consultant of: BMS, Celgene, Celltrion, Galapagos, Gilead, Janssen-Cilag, Lilly, Novartis, Pfizer, Sanofi-Genzyme, Grant/research support from: Abbvie

POS0648 SURVIVAL ANALYSIS OF TIME TO FIRST ADVERSE DRUG REACTION AND DRUG SURVIVAL IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH METHOTREXATE AND HYDROXYCHLOROQUINE MONOTHERAPIES OR COMBINATION THERAPY

Background:

Methotrexate (MTX) and hydroxychloroquine (HCQ) are first line treatments of rheumatoid arthritis (RA). Adverse drug reactions (ADRs) during treatment with these drugs are common. Survival analysis on time to first ADR and on first time drug use duration have not yet been performed for these drugs in real-world settings.

Objectives:

To compare proportions of patients with ADRs during first time use of either MTX monotherapy, HCQ monotherapy or MTX+HCQ combination therapy and to compare survival to first ADR and drug survival between these drugs.

Methods:

Retrospective single centre cohort study including adult RA patients treated with either MTX monotherapy, HCQ monotherapy or MTX+HCQ combination therapy. First time users between 1 January 2003 and 30 April 2020 were followed until discontinuation of their first time drug use. The proportion of patients with ADRs was defined as the percentage of patients experiencing an ADR during their first time drug use. Survival to first ADR and drug survival of first time drug use were also assessed. MTX+HCQ use was considered combination therapy when the start dates of these drugs differed less than 14 days. For both monotherapies, end of first time drug use was defined as drug discontinuation for more than 90 days. For MTX+HCQ combination therapy, end of first time drug use was defined as discontinuation of either MTX, HCQ or both for more than 90 days. Differences in the proportion of patients experiencing an ADR during first time drug use of MTX, HCQ or a combination of both was statistically tested using Fisher’s Exact Test. Survival to first ADR and drug survival were studied by Kaplan-Meier analysis and statistically tested by performing Log Rank tests.

Results:

In total, 794 patients were included (MTX 363, HCQ 77, MTX+HCQ 354). For 156 patients (19.6%) at least one ADR was registered during first time drug use (MTX 59 [16.3%], HCQ 9 [11.7%], MTX+HCQ 88 [24.9%]). Proportions of ADRs differed significantly between MTX monotherapy and MTX+HCQ combination therapy (p=0.005) and between HCQ monotherapy and MTX+HCQ combination therapy (p=0.011). Survival to first ADR also differed significantly for both monotherapies compared to MTX+HCQ combination therapy (medians not reached, p<0.001 and p<0.008, respectively (figure 1A)). Drug survival differed significantly between MTX and HCQ monotherapy and between MTX monotherapy and MTX+HCQ combination therapy (median survival MTX 3.32 years (95% CI [2.81-3.83]; HCQ 1.39 years (95% CI [1.03-1.75]); MTX+HCQ 1.23 years (95% CI [1.11-1.34]), both p<0.001 (figure 1B)).

Figure 1.

Kaplan-Meier curves of MTX and HCQ monotherapies and MTX+HCQ combination therapy, with (a) survival to first ADR and (b) drug survival.

Conclusion:

Patients using MTX+HCQ combination therapy are more likely to experience an ADR during the first time drug use compared to MTX and HCQ monotherapies. MTX+HCQ combination therapy also leads to experiencing an ADR sooner compared to both monotherapies. Drug survival of patients treated with HCQ monotherapy as well as MTX+HCQ combination therapy is shorter compared to MTX monotherapy.

Disclosure of Interests:

Kimberly Velthuis: None declared, My Nguyen: None declared, Joep Scholl: None declared, Jurriaan Jansen: None declared, Jette van Lint: None declared, Peter ten Klooster: None declared, Harald Vonkeman Consultant of: BMS, Celgene, Celltrion, Galapagos, Gilead, Janssen-Cilag, Lilly, Novartis, Pfizer, Sanofi-Genzyme, Grant/research support from: Abbvie, Naomi Jessurun: None declared