Advanced therapies in patients with rheumatoid arthritis in moderate disease activity: a single-centre experience

Abstract Background/Aims In England, patients with rheumatoid arthritis (RA) with Moderate Disease Activity (MDAS), assessed by the DAS28 measure, had been unable to access effective therapies. We and others have reported that this group has persistent active disease, progressive joint damage, poor function and quality of life for years. In 2021 NICE published Technology Appraisals, 676, 715 and 744, which provided these patients with access to effective advanced therapies. We audited our response to these new standards from their approval in 2021. Methods Virtual Biologics Clinic (VBC) electronic records were analysed for details of patients with RA with DAS28 scores ≥3.2 to ≤ 5.1 who were approved for advanced therapies and their response to therapy. Response is reported as those who achieved DAS28 remission or low disease activity (LDAS), the usual goals of therapy for treat to target in patients with RA. Adverse events and reasons for adopting oral therapies were recorded. Results Local approval was granted for filgotinib in May 2021, adalimumab, etanercept and infliximab in October 2021, and upadacitinib in February 2022. From May 2021 until 30 August 2022, 49 patients with MDAS status RA have been approved by our VBC process. Of these, 3 declined advanced therapy after approval, 25 started adalimumab, 14 filgotinib, 4 etanercept, 1 certolizumab pegol (planned pregnancy) and 2 with a mixed RA/CTD diagnosis, rituximab. The mean DAS28 score was 4.32, range 3.22-5.1, with 20 having a DAS28 score >4.5. 29 patients had failed two DMARDS, 18 triple therapy and 2 patients failed 4 DMARDs. Most patients starting filgotinib strongly preferred oral therapy and one was a frequent traveller. Of the 18 patients receiving TNFi therapy who had at least 3 months therapy for initial disease response assessment, 8 achieved DAS 28 remission, 5 LDAS, 3 unchanged and 2 primary failure. In the 11 patients receiving filgotinib for at least three months, 7 achieved DAS28 remission, 2 LDAS, 1 primary failure and I was lost to follow-up. No patients stopped for adverse events to date. Conclusion Our preliminary data describing the use of advanced therapies in this previously under-treated group of patients with RA, show that good responses occur in many. A high percentage achieve remission, the primary goal of treat-to target guided therapy in RA. Disclosure F. Humby: Honoraria; Galapagos, Roche. Grants/research support; Pfizer. S. Subesinghe: None. A. Cope: Honoraria; Abbvie. B. Menon: None. R. Byng-Maddock: None. N. Ladha Hassan: None. L. Blackler: Honoraria; Abbvie, Novartis, UCB. Z. Mckee: None. K. Topping: None. L. Marsh: None. T. Garrood: Honoraria; UCB. Grants/research support; Galapagos, Pfizer. N. Ng: None. B.W. Kirkham: Honoraria; Abbvie, Galapagos, Janssen, Lilly, Novartis, PfizerUCB. Grants/research support; Lilly, Novartis.