EULAR Express: How to choose first-line and second-line options for the treatment of AS with biological agents?

*Only for medical professionals to read and reference.
In the real world, TNFi is the first-line bio-treatment plan for most axSpA patients~Affected by the global new crown pneumonia epidemic, the 2021 European Union Against Rheumatism (EULAR) annual meeting is still held in the form of a web conference
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Rheumatology experts and scholars from all over the world gathered online to exchange cutting-edge results and share academic views
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At this EULAR conference, the popularity of biological preparations is not diminished, and it is still the focus of attention
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TNF inhibitors (TNFi) are the earliest biological agents used in the treatment of AS, and are currently the most commonly used type of biological agents in clinical practice.
Many authoritative guidelines around the world recommend them as the first-line treatment of biological agents
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If TNFi treatment is not effective clinically, should I switch to another TNFi or switch to other target biological agents? What is the difference in the retention rate of biological agents for different targets in clinical practice? Some researchers have explored this and published the results at the EULAR conference
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This article will extract the essence for readers
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TNFi is mostly used as the first-line treatment of biological agents.
A multi-center, retrospective observational study included 370 patients with axial spondyloarthritis (axSpA) who initiated TNFi or IL-17i treatment between June 2016 and December 2019.
) Patients, the researchers evaluated the long-term survival rate of the two biological agents in the real world and the reasons for discontinuation [1]
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There was no significant difference between the two groups of patients in indicators such as gender ratio, age, BMI, course of disease, and average BASDAI score
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It should be noted that among the patients who used TNFi, 116 (57.
4%) patients used biologics for the first time, while in the IL-17i group, only 8.
9% (15/168) used biologics for the first time (Figure 1)
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This shows that in real-world clinical practice, TNFi is still the most commonly used first-line biological therapy
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Figure 1 The proportion of patients who used biological agents for the first time in the two groups.
The three-year follow-up showed that the drug retention rate in the TNFi group was higher than that of IL-17i
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The median duration was 18 months in the TNFi group and 12 months in the IL-17i group (Figure 2)
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Figure 2 The drug retention rate of IL-17i group varies with the duration of treatment.
The data show that in the real world, patients with axSpA have long-term use of TNFi, and the withdrawal rate is lower than that of IL-17i patients
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In addition, patients who use TNFi have similarly lower withdrawal rates due to lack of efficacy and adverse reactions (Figure 3, Figure 4, and Figure 5)
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Figure 3 Proportion of patients discontinued in the two groups Figure 4 Proportion of patients in the two groups discontinued due to lack of efficacy Figure 5 Proportion of patients discontinued due to adverse reactions in the two groups The study shows that in the real world, TNFi is still the biological treatment for most patients First-line option, relatively speaking, IL-17i is often used in second-line or even third-line treatment
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Compared with TNFi, IL-17i long-term treatment of axSpA patients has a higher rate of discontinuation, and the main reason for discontinuation is invalid or adverse reactions
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AS patients who have used TNFi can still consider another TNFi.
A Korean study included AS patients registered in the Biologics Registry of the Korean Academy of Rheumatology.
Among them, 246 patients who had used TNFi were classified according to the conversion treatment plan.
TNFi conversion group and IL-17i group
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During the 1-year follow-up period, the investigator evaluated the drug retention rate and clinical efficacy (BASDAI 50 response rate, ASAS 20 response rate, ASAS 40 response rate, ratio of ASDAS <2.
1, clinically important improvement of ASDAS and major improvement of ASDAS) [ 2]
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The results show that IL-17i is more commonly used in third-line or later treatment options than TNFi (that is, patients have used two or more biological agents when they initiate IL-17i therapy) (Figure 6)
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Figure 6 Proportion of patients who used two or more biologics before IL-17i or TNFi was used.
The data of two groups of patients were analyzed by propensity matching and multiple covariate adjustment.
The results showed that AS patients converted from one TNFi to IL-17i and switching to another TNFi had the same risk of discontinuation (propensity matching analysis OR=1.
136, 95% CI 0.
843-1.
531, multiple adjustment analysis OR=1.
000, 95% CI 0.
433-2.
308)
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In terms of efficacy, there was no significant difference in the BASDAI 50 response rate between the two groups (propensity matching analysis OR=0.
833, 95%CI 0.
481–1.
441)
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In addition, the end points of other studies are basically the same
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Studies have confirmed that for AS patients who have received TNFi treatment, switch the treatment plan to another TNFi or IL-17i.
The drug retention rate and drug efficacy of the two are basically the same, and there is no significant difference
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A study from Switzerland published in the "Rheumatism Yearbook" in 2020 also reached a similar conclusion [3]
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The study included 390 axSpA patients who had been treated with TNFi.
The results showed that 76% of the patients treated with IL-17i were used as the third-line regimen of biological therapy or later
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The patient changes from one type of TNFi to another type of TNFi or IL-17i, and the risk of discontinuation is equivalent (HR=1.
14, 95% CI 0.
78-1.
68)
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There was no significant difference between the two groups of patients in the data of efficacy endpoints such as BASDAI 50 (Figure 7)
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Figure 7 After switching treatment, there was no significant difference in the efficacy endpoint between the two groups.
Note: The results of propensity matching analysis are black, and the results of multivariate adjustment analysis are gray.
These research results fully indicate that for patients who have been treated with TNFi, the second-line treatment plan Another TNFi can still be considered
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In current clinical practice, IL-17i is often used as a third-line or later treatment option for biologics treatment
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Summary: In the real world, TNFi is the first-line biotherapy treatment for most axSpA patients
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The discontinuation rate of TNFi for long-term treatment of axSpA is low
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IL-17i is often used as a third-line or later option for biologic therapy
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For AS patients who have used TNFi, the efficacy of switching to TNFi or IL-17i is basically the same as the drug retention rate
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 Expert profile Chen Zhiyong, director, Deputy Chief Physician, Department of Rheumatology and Immunology, Shanghai Sixth People's Hospital, Shanghai Jiaotong University Chairman, Youth Committee, Jiangsu Society of Immunology, Youth Committee, Rheumatology Branch of Jiangsu Society of Integrative Medicine, Keio University School of Medicine, Japan, and Hopkins University School of Medicine, Visiting Scholar Reference: [1]T.
Delepine,et al.
EULAR 2021,June 2-5,2021,AB0464.
[2]HKMin,et al.
EULAR 2021,June 2-5,2021,AB0466.
[3]Micheroli R,et al.
Ann Rheum Dis.
2020 Sep;79(9 ): 1203-1209.