Five-year drug survival and discontinuation reasons for eight biological disease-modifying antirheumatic drugs for rheumatoid arthritis: A retrospective analysis of 1,182 patients from the Niigata Orthopedic Surgery Rheumatoid Arthritis Database (NOSRAD)

Background Continuity of care of patients with rheumatoid arthritis, afforded by treatment in a single institution under the same attending physician, reduces outpatient attrition and enables a stable collection of long-term clinical data. However, our prefecture, like many regional areas in Japan, faces a chronic shortage of board-certified rheumatologists. Therefore, we aimed to determine the five-year drug-survival and discontinuation reasons for eight biological disease-modifying antirheumatic drugs (bDMARDs) for rheumatoid arthritis using Japan’s Niigata Orthopedic Surgery Rheumatoid Arthritis Database. Methods Between May 2001 and August 2022, 1,182 patients were retrospectively analyzed. Naïve (n = 784) and switch (n = 398) patients initiated their first or subsequent bDMARD, respectively. The primary end-point was five-year drug-survival per bDMARD while the secondary analyses assessed methotrexate (MTX) co-therapy, discontinuation risk factors, and cumulative incidence of discontinuation reasons. Kaplan–Meier curves, Cox (stratified by drug), and Fine & Gray models were applied. Results Naïve cohort showed significant inter-drug differences in sex, age, disease duration, 28-joint Disease Activity Score with erythrocyte-sedimentation-rate (DAS28-ESR), MTX or prednisolone (PSL) co-therapy, and PSL dose. Switch cohort differed by age, disease duration, DAS28-ESR, MTX co-therapy, PSL dose, and treatment line. Five-year drug-survival in naïve cohort ranged from tocilizumab (50.8%) to golimumab (22.6%); in switch cohort, from abatacept (42.6%) to infliximab (10.0%). Cox analysis in naïve cohort found male sex, lower baseline DAS28-ESR, and no MTX predicted discontinuation, explained by inadequate response (27.1%), adverse events (17.3%), and non-adverse events (25.3%). Conclusions Early, individualized drug selection and dose optimization are crucial to maximize long-term bDMARD effectiveness before switching.