Real-World Implementation of Treatment Intensification After Methotrexate in Rheumatoid Arthritis in the Context of Treat-to-Target Recommendations: Insights From Japan’s Claims Data

OBJECTIVES: To describe real-world treatment patterns in Japanese patients with rheumatoid arthritis, focusing on intensification after methotrexate and prescribing patterns of methotrexate and glucocorticoids, in the context of treat-to-target strategy. METHODS: This was a retrospective cohort study using claims database. Adults with rheumatoid arthritis who initiated methotrexate were included and classified by treatment intensification within 210 days (6 months, as per the guideline, plus a 30-day grace period) into three groups: (1) intensified to conventional synthetic disease-modifying antirheumatic drugs, (2) intensified to biologic or targeted synthetic disease-modifying antirheumatic drugs, or (3) remained on methotrexate monotherapy. Methotrexate and glucocorticoid dose transitions were visualised using Sankey diagrams. RESULTS: Of 21,734 patients, 13,784 (63.4%) remained on methotrexate monotherapy and 4,949 (22.8%) received intensification (63.8% intensified with synthetic disease-modifying antirheumatic drugs and 34.8% with biologic or targeted synthetic disease-modifying antirheumatic drugs). In the intensified subgroups, 40% used glucocorticoids for >90 days, and 80% had a daily dose >5 mg; approximately 30% received a methotrexate dose <6 mg when transitioned to second-line therapy. CONCLUSIONS: The low intensification rate within 6 months, predominance of synthetic disease-modifying drugs, insufficient methotrexate dose escalation, and long-term use of glucocorticoids suggest a gap between real-world clinical practice and guideline recommendations.