Ab0230 Switching From TNF Inhibitors to Tofacitinib Among Patients With Stable Disease Due to Cost Implications: Differential Loss of Response in Majority of Patients With Inflammatory Arthropathies

Background: Tumor necrosis factor inhibitors (TNFi) are a common choice as first-line drugs to treat inflammatory arthropathies. Although this form of treatment has revolutionised the management of RA, approximately one third of patients don't respond effectively. Options usually at this stage is to "cycle" to another TNFi or to "switch" to another drug with a different mechanism of action (MOA). Recent meta-analysis shows that "switching" to a drug with a different MOA such as Janus Kinase inhibitors (JAKi) is a better treatment strategy. In a number of Asian countries, JAKi are available at a significantly lower price compared to biologic DMARDs (bDMARDs), and given its oral availability further adds to the pressure of its prescribing for rheumatologists. Objectives: Very little is known regarding those patients who already have very good response with TNFi but needed switching to JAKi because of cost implications. We describe here our real-world experience of managing such cohort of patients. Methods: This prospective study included patients with inflammatory arthropathies who were treated using TNFi between January 2021 through to July 2023 at Fatima Memorial Hospital, and Doctors Hospital & Medical Centre, Lahore. Overall, 592 patients (RA=376, AS=135, PsA=81) had continued their TNFi therapy with an observation period of 1005 patient-years during the baseline study period. Our patients used following TNFi: infliximab=511 (Biosimilar 120mg subcutaneous every 14th day), and etanercept=81. There were very few patients using Adalimumab (n=8), which is not easily available in Pakistan, and hence such patients were excluded. These patients have effective control of their disease, and hence earlier decision made was to continue TNFi therapy; for example, 80.5% of this cohort (n=477) had their disease in remission and the rest have low disease activity. However, significant cost implications hampered our efforts to continue providing bDMARDs in the long run, and decision was made to switch these patients to JAKi. Results: Untill the end of December 2023, overall 421 out of 592 (71%) patients with adequate disease control [392 out of 511 (76.7%) INF patients and 29 out of 81 (35.8%) ETN patients] were switched to oral Tofacitinib therapy. Out of these 421 patients, 54% (n=229) of patients had a flare of underlying inflammatory arthritis within 8 weeks of switching therapy. There were only 21 patients who achieved remission after a short rescue therapy of corticosteroids. Rest of patients (171) continued to have active disease and needed either escalation of baseline DMARDs therapy, or higher dose of Tofacitinib, or maintenance of low dose corticosteroids, or switching back to TNFi. It was interesting to note that 70% (n=82) of AS patients, 64% (n=39) of PsA patients and only 44% (n=108) of RA patients have relapse of their disease after switching their therapy. Conclusion: There is paucity of data as regards switching therapy among patients with adequate disease control. Our prospective study shows that majority of patients have relapse of their inflammatory arthritis, and it was significantly higher among patients with AS, with 70% of patients having relapse of their disease. REFERENCES: NIL. Acknowledgements: NIL. Disclosure of Interests: None declared.