OP0179 Comparing Initial Treatment Strategies with Methotrexate on First Use of Biologic Therapy: Results from The Canadian Early Arthritis Cohort
Authors: S. Gottheil, J. Pope, O. Schieir, G. Hazlewood, E. Keystone, S. Jamal, C. Barnabe, G. Boire, C. Hitchon, C. Thorne, V. Bykerk, D. Tin, P. Haraoui
Journal: Annals of the Rheumatic Diseases (2016)

<h3>Background</h3> Optimal treatment of early rheumatoid arthritis (ERA) involves a treat-to-target strategy aiming for remission. Initial use of combination DMARDs is associated with an increased likelihood of remission in ERA patients. Research suggests that combinations DMARDs can provide equivalent outcomes at lower costs than biologic DMARDs. <h3>Objectives</h3> To compare effects of initial treatment with methotrexate (MTX) monotherapy vs MTX combination therapy on time to first use of biologic DMARDs in a large multi-centre ERA cohort. <h3>Methods</h3> The Canadian Early Arthritis Cohort (CATCH) is a multi-centre prospective cohort study of patients with early RA diagnosed and treated by a rheumatologist. The present study included participants who met 1987 or 2010 ACR criteria for RA, with ≤12 months symptom duration, moderate or high disease activity based on the DAS28 at baseline and treated with MTX. Patients treated with a biologic at baseline were excluded. Patients were followed until they started a biologic or they were censored due to loss to follow up or the end of the 3-year study period. Cox proportional hazards survival analysis was used to estimate effects of oral MTX monotherapy, subcutaneous MTX monotherapy, and MTX combination therapy adjusting for age, gender, education level, symptom duration, comorbidities, seropositivity, baseline erosions, baseline DAS28, and corticosteroid use. <h3>Results</h3> 1214 patients were included with 212 first events of biologic use. At baseline, 865 (71.3%) were female with mean (sd) age of 54.4 (14.9) years, symptom duration of 5.5 (2.8) months, and DAS28 of 5.5 (1.2). Oral MTX monotherapy was used as initial treatment in 230 (19%), subcutaneous MTX monotherapy in 226 (19%), and MTX combination therapy in 730 (62%). In fully adjusted Cox regression models, patients treated with subcutaneous MTX monotherapy were half as likely to require biologics as patients treated with oral MTX monotherapy (HR =0.47, p=0.015). There was no difference between MTX combination therapy and oral MTX monotherapy (HR =0.95). <h3>Conclusions</h3> Treatment with subcutaneous MTX monotherapy was associated with a reduced use of biologics. This may be due to increased treatment efficacy compared to oral MTX. Combination DMARD therapy was not associated with longer time to biologic initiation, potentially due to funding models in Canada specifying that combination DMARD therapy must be used before biologics can be considered. This study suggests that early use of subcutaneous MTX can potentially delay the need for more expensive biologic therapies. <h3>References</h3> Joensuu JT, Huoponen S, Aaltonen KJ, et al. The cost-effectiveness of biologics for the treatment of rheumatoid arthritis: a systematic review. PLoS One 2015; 10:e0119683. Scott DL, Ibrahim F, Farewell V, et al. Tumour necrosis factor inhibitors versus combination intensive therapy with conventional disease modifying anti-rheumatic drugs in established rheumatoid arthritis: TACIT non-inferiority randomised controlled trial. BMJ 2015; 350:h1046–h1046. <h3>Disclosure of Interest</h3> S. Gottheil Grant/research support from: Amgen Canada Inc, Pfizer Canada Inc, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation, Janssen Inc, Medexus Inc and Eli Lilly Canada Inc, J. Pope Grant/research support from: Amgen Canada Inc, Pfizer Canada Inc, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation, Janssen Inc, Medexus Inc and Eli Lilly Canada Inc, O. Schieir Grant/research support from: Amgen Canada Inc, Pfizer Canada Inc, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation, Janssen Inc, Medexus Inc and Eli Lilly Canada Inc, G. Hazlewood Grant/research support from: Amgen Canada Inc, Pfizer Canada Inc, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation, Janssen Inc, Medexus Inc and Eli Lilly Canada Inc, E. Keystone Grant/research support from: Amgen Canada Inc, Pfizer Canada Inc, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation, Janssen Inc, Medexus Inc and Eli Lilly Canada Inc, S. Jamal Grant/research support from: Amgen Canada Inc, Pfizer Canada Inc, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation, Janssen Inc, Medexus Inc and Eli Lilly Canada Inc, C. Barnabe Grant/research support from: Amgen Canada Inc, Pfizer Canada Inc, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation, Janssen Inc, Medexus Inc and Eli Lilly Canada Inc, G. Boire Grant/research support from: Amgen Canada Inc, Pfizer Canada Inc, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation, Janssen Inc, Medexus Inc and Eli Lilly Canada Inc, C. Hitchon Grant/research support from: Amgen Canada Inc, Pfizer Canada Inc, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation, Janssen Inc, Medexus Inc and Eli Lilly Canada Inc, C. Thorne Grant/research support from: Amgen Canada Inc, Pfizer Canada Inc, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation, Janssen Inc, Medexus Inc and Eli Lilly Canada Inc, V. Bykerk Grant/research support from: Amgen Canada Inc, Pfizer Canada Inc, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation, Janssen Inc, Medexus Inc and Eli Lilly Canada Inc, D. Tin Grant/research support from: Amgen Canada Inc, Pfizer Canada Inc, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation, Janssen Inc, Medexus Inc and Eli Lilly Canada Inc, P. Haraoui Grant/research support from: Amgen Canada Inc, Pfizer Canada Inc, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation, Janssen Inc, Medexus Inc and Eli Lilly Canada Inc