University of Western Ontario, London; Saint Joseph's Health Care, London, ON, Canada.
JSS Medical Research, St-Laurent, QC, Canada.
Clin Exp Rheumatol. 2018 Mar-Apr;36(2):215-222. Epub 2017 Oct 23.
In active rheumatoid arthritis (RA) patients with inadequate response to methotrexate (MTX), guidelines support adding or switching to another conventional synthetic disease-modifying anti-rheumatic drug (csDMARD) and/or a biologic DMARD (bDMARD). The purpose of this analysis was to describe treatment practices in routine care and to evaluate determinants of regimen selection after MTX discontinuation.
Biologic-naïve patients in the Ontario Best Practice Research Initiatives registry discontinuing MTX due to primary/secondary failure, adverse events, or patient/physician decision were included.
Of 313 patients discontinuing MTX, 102 (32.6%) were on MTX monotherapy, 156 (49.8%) on double, and 55 (17.6%) on multiple csDMARDs. Patients on MTX monotherapy were older than patients on double or multiple csDMARDs (p=0.013), less likely to have joint erosions (p=0.009) and had lower patient global assessment (p=0.046) at MTX discontinuation. Post-MTX discontinuation, 169 (54.0%) transitioned to, or added new DMARD(s) (new csDMARD(s): 139 [44.4%]; bDMARD: 30 [9.6%]), and 144 (46.0%) opted for no new DMARD treatment. Patients on MTX monotherapy transitioning monotherapy, whereas patients on combination csDMARDs switched more to new csDMARDs and bDMARD combination therapy. Early RA (adjOR [95%CI]: 3.07 [1.40-6.72]) and treatment with multiple csDMARDs vs. MTX monotherapy (4.15 [1.35-12.8]) at MTX discontinuation were significant predictors of transitioning to or adding new csDMARD(s)/bDMARD treatment versus opting for no new DMARD treatment.
Differences in subsequent treatment patterns exist between patients discontinuing MTX when used as monotherapy versus in combination with other csDMARDs where the former are more likely to use a subsequent monotherapy treatment.
在甲氨蝶呤（MTX）治疗反应不足的活动性类风湿关节炎（RA）患者中，指南支持加用或改用另一种传统合成改善病情抗风湿药（csDMARD）和/或生物 DMARD（bDMARD）。本分析的目的是描述常规治疗中的治疗实践，并评估 MTX 停药后方案选择的决定因素。
在安大略省最佳实践研究倡议登记处，因原发/继发失效、不良反应或患者/医生决定而停用 MTX 的生物初治患者被纳入研究。
在 313 例停用 MTX 的患者中，102 例（32.6%）接受 MTX 单药治疗，156 例（49.8%）接受双药治疗，55 例（17.6%）接受多种 csDMARD 治疗。MTX 单药治疗的患者比接受双药或多种 csDMARD 治疗的患者年龄更大（p=0.013），在 MTX 停药时更不可能有关节侵蚀（p=0.009），且患者整体评估（PGA）更低（p=0.046）。在 MTX 停药后，169 例（54.0%）转为或加用新的 DMARD（新的 csDMARD：139 例[44.4%]；bDMARD：30 例[9.6%]），144 例（46.0%）未选择新的 DMARD 治疗。MTX 单药治疗的患者转为单药治疗，而联合 csDMARD 治疗的患者更多地转为新的 csDMARD 和 bDMARD 联合治疗。MTX 停药时为早期 RA（调整比值比[95%CI]：3.07[1.40-6.72]）和使用多种 csDMARD 治疗而非 MTX 单药治疗（4.15[1.35-12.8]）是转为或加用新的 csDMARD/bDMARD 治疗而非选择不使用新 DMARD 治疗的显著预测因素。
与 MTX 联合其他 csDMARD 治疗相比，MTX 单药治疗时停药的患者在随后的治疗模式上存在差异，前者更可能使用后续的单药治疗。
