Prescribing Patterns for Second-Line Treatment of Rheumatoid Arthritis

Laura Joszt, MA
Laura Joszt, MA

Laura is the editorial director of The American Journal of Managed Care® (AJMC®) and all its brands, including The American Journal of Accountable Care®, Evidence-Based Oncology™, and The Center for Biosimilars®. She has been working on AJMC® since 2014 and has been with AJMC®'s parent company, MJH Life Sciences, since 2011. She has an MA in business and economic reporting from New York University.

Despite the benefits of switching to a different mode of action in the second line, almost half of patients with rheumatoid arthritis were cycled to a second tumor necrosis factor inhibitor.

Tumor necrosis factor (TNF) inhibitors are the most commonly prescribed targeted therapy for first-line treatment of patients with rheumatoid arthritis (RA) in Europe and Japan, and almost half of patients are cycled to a second TNF inhibitor in the second line despite the benefits of switching to a different mode of action (MOA), according to a study in Rheumatology and Therapy.

The researchers analyzed treatment patterns of patients in 5 European countries (EU5; France, Germany, Italy, Spain, and the United Kingdom) and Japan using data from the Adelphi Real World RA Disease Specific Programme.

“With the number of treatment options increasing for patients with RA, there is a growing need to understand prescribing patterns and behaviors to help optimize treatment outcomes,” the authors explained.

In the EU5, the study sample included 3088 patients being seen by 301 rheumatologists. In Japan, the sample included 347 patients seen by 47 physicians. The first targeted therapy prescribed could be identified for 2006 EU5 patients and 147 Japanese patients. A similar proportion were prescribed combination therapy: 76.0% of EU5 patients and 77.6% of Japanese patients.

Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) were the most commonly prescribed therapy prior to a first-line targeted therapy (84.7% in the EU5 and 78.6% in Japan), and the most common csDMARD was methotrexate (91.5% and 87.3%, respectively). The second most common therapy were nonsteroidal anti-inflammatory drugs (42.7% and 43.6%, respectively).

Approximately three-fourths (73.5%) of EU5 patients reached the maximum csDMARD dose before they were prescribed a first-line targeted therapy. However, less than half (45.7%) of patients in Japan had reached the maximum csDMARD dose before being prescribed a first-line targeted therapy.

The majority of EU5 patients (80.8%) and Japanese patients (64.6%) were prescribed a TNF inhibitor for their first-line targeted therapy. Only 19.2% of EU5 patients and 31.3% of Japanese patients were prescribed a non-TNF inhibitor. Additionally, 6 (4.1%) Japanese patients were prescribed a targeted synthetic DMARD. At the time of data collection, tofacitinib was approved but not yet available.

In the EU5, 365 patients who received a TNF inhibitor in the first line progressed to second-line targeted therapy and almost half (47.9%) received another TNF inhibitor while 52.1% switched MOA. Of the 22 Japanese patients who received a TNF inhibitor in the first line and progressed to second-line targeted therapy, 45.5% received another TNF inhibitor and 54.5% were MOA switchers.

Among EU5 patients who switched to a different MOA, disease severity, based on physician reporting, was significantly worse than patients who went to another TNF inhibitor (P < .05). However, the authors noted that since disease severity was based on what physicians reported in a survey and not a disease activity score at 28 joints, it could be subjective and variable.

“Despite the demonstrated benefits associated with MOA switching, almost half of patients were cycled to another TNF [inhibitor],” they concluded. “These results suggest that physicians in [the] EU5 and Japan generally follow treatment guidelines but prescribe how they choose, providing optimized and individualized treatments for their patients.”


Sullivan E, Kershaw J, Blackburn S, Mahajan P, Hoklage SH. Biologic disease-modifying antirheumatic drug prescription patterns among rheumatologists in Europe and Japan. Rheumatol Ther. 2020;7(3):517-535. doi:10.1007/s40744-020-00211-w