Switching First-Line Targeted Therapy After Not Reaching Low Disease Activity Within Six Months is Superior to Conservative Approach: A Propensity Score Matched Analysis From The ATTRA Registry

Background: Treat-to-target (T2T) is a widely accepted strategy for patients with rheumatoid arthritis (RA). It recommends attaining a goal of at least low disease activity (LDA) within six months; otherwise, the current therapy should be modified. We aimed to investigate whether switching a first-line targeted therapy (TT) in patients not reaching LDA within six months leads to a higher probability of meeting LDA at 12‑month visit in daily clinical practice using data from Czech registry ATTRA.

Methods: We included patients with RA starting the first-line TT from 1 January 2012 to 31 January 2017 with at least one-year follow-up. We created four mutually exclusive cohorts based on 1) switching to another TT within the first year and 2) reaching a treatment target (DAS28-ESR ≤ 3.2) at the 6‑month visit. The primary outcome was the comparison of odds for reaching remission (REM) or LDA at the 12-month visit between patients switching and not switching TT after not reaching treatment target at six months. Before using logistic regression to estimate the odds ratio, we employed the propensity score to match patients at the 6-month visit.

Results: A total of 1275 patients were eligible for the analysis. Sixty-two patients switched within the first five months of the treatment before evaluating treatment response at the 6-month visit (C1); 598 patients reached the treatment target within six months of therapy (C2); 124 patients did not reach treatment response at 6-month visit and switched to another therapy (C3), and 491 patients continued with the same treatment despite not reaching LDA at the 6‑month visit (C4). We matched 75 patients from cohort C3 and 75 patients from C4 using the propensity score. Patients following T2T principle (C3) showed 2.8 (95% CI 1.4–5.8; p=0.005) times increased likelihood of achieving REM/LDA at 12‑month visit compared to patients not following T2T strategy (C4).

Conclusions: In daily clinical practice, the application of T2T strategy is underused. Switching TT after not reaching REM/LDA within the first six months leads to a higher probability of achieving REM/LDA in RA patients at the 12-month visit.