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Guideline recommendations for use of tumor necrosis factor (TNF) inhibitors in people with rheumatoid arthritis (RA) were only infrequently followed in independent, community-based rheumatology practices, researchers found.

In an analysis of treatment patterns among practices participating in the American Rheumatology Network (ARN), just 44.8% of RA patients starting on TNF inhibitors received a formal baseline disease activity assessment, according to Patrick Zueger, PharmD, PhD, of AbbVie in Chicago, and colleagues.

More than half of the others did not even have a swollen/tender joint count or pain level recorded, the group .

Furthermore, just over half of patients with moderate/severe RA subsequently stopped their TNF inhibitor; of these, 15% restarted the exact same drug and another 46% were given a different TNF inhibitor. Evidence indicates that neither approach is optimal for patients who discontinue initial TNF inhibitor therapy. Only 40% were switched to a drug not targeting TNF, such as abatacept (Orencia) or a Janus kinase (JAK) inhibitor, as recommended in published guidelines.

Zueger and colleagues noted that payer issues might have driven some of these decisions. Getting patients to restart the same drug or a closely related one may not require prior authorization from the insurer, whereas one might well be demanded if the patient is prescribed an entirely different type of medication. But the researchers were less sympathetic to the lack of baseline disease activity assessments, which, they said, can be performed in "less than 2 minutes" during a standard office visit.

And Zueger's group was particularly exasperated that so many RA patients were cycled through various TNF inhibitors even though lack of efficacy was the most common reason for stopping treatment. For 25% of discontinuations, it was the only reason for cessation, and a combination of poor efficacy and excessive side effects was cited in 27% of cases. (Some 20% of discontinuations were for tolerability only, and 16% were for reasons unrelated to tolerability or effectiveness.)

Current guidelines call for rheumatologists to perform a formal disease activity assessment when starting RA drug therapy, using the Clinical Disease Activity Index (CDAI) or other standardized scoring methods, so that treatment efficacy or its lack can be tracked systematically. These scoring systems also allow for a treat-to-target approach, with low disease activity or clinical remission as the targets.

Patients should be rechecked periodically, with a change in treatment considered for those not reaching their targets. Moreover, the guidelines recommend that patients not responding to or unable to tolerate their first therapy (normally a TNF inhibitor) be switched to a different medication class, rather than a different member of the original class.

To examine treatment patterns among rank-and-file rheumatologists, Zueger and colleagues drew on the , a consortium of more than 200 community-based U.S. rheumatologists that systematically collects deidentified patient data via the practices' electronic records systems. In these data from 2014 to 2020, the researchers counted more than 15,000 patients who started a TNF inhibitor.

About 30% of these patients discontinued their first drug within 6 months, reaching 47% by 1 year. Yet remaining on therapy was no guarantee that it was actually working: Zueger's group found that half of patients with moderate/severe disease (as established through CDAI or similar assessments) were still on their initial TNF inhibitor after 1 year "despite no evidence of achieving treatment targets" of low disease activity or remission. More than one-third of patients stayed on TNF inhibitors for 3 years without reaching such targets.

Another sobering result in the study: substantial number of patients who discontinued their first drug had no record of trying another. This was true for 15% of those discontinuing because of poor efficacy, 35% of those citing adverse effects, and a startling 43% of patients quitting for issues unrelated to effectiveness or tolerability (Zueger and colleagues speculated that payer issues were an important contributor to the latter finding).

Zueger and colleagues acknowledged that deviating from guideline recommendations may be appropriate in individual cases, noting that comorbidities and/or other medications that patients are taking may dictate a different treatment plan.

"Future studies are needed to assess what drives treatment decision-making in order to better inform treatment guidelines and ensure that patients are not languishing on ineffective therapies," they wrote.

They also pointed out that use of formal baseline assessments increased markedly over time during the study period, reaching 65% in the final year; in 2014, just 16% of patients received one.

Since the study relied on administrative data, the possibility of errors could not be discounted. As well, ARN participants are not necessarily representative of all U.S. rheumatologists, nor are their patients necessarily representative of the general RA population (although their general demographics in the current study appeared typical).

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