Objective: For patients with Rheumatoid Arthritis (RA) who do not achieve adequate
clinical response with combined conventional synthetic disease-modifying anti-rheumatic drugs (cs-
DMARDs), initiation of advanced therapies such as biologic DMARDs (bDMARDs) or targeted
synthetic DMARDs (tsDMARDs) is recommended. Tumour necrosis factor inhibitors (TNFi) are
the oldest and most commonly used subgroup of advanced therapies. In the last decade, new non-TNFi
advanced therapy options have become available. We described the relative use of TNFi vs.
non-TNFi in Ontario-based practices from 2008-2017.
Methods: Adult patients with RA enrolled in the Ontario Best Practices Research Initiative (OBRI)
database who started bDMARDs or tsDMARDs anytime during or within 30 days prior to enrollment
were included. The proportion of patients treated with TNFi vs. non-TNFi agents between
2008 and 2017 was described for all patients and those initiating their first bDMARD/tsDMARD.
All TNFi therapies were included. Non-TNFi included Abatacept, Rituximab, Tocilizumab, and Tofacitinib.
Results: A total of 1,057 patients were included, of whom 72.0% were bDMARD/tsDMARD
naïve. In 2008, the relative non-TNFi use was 5.4% in all patients while it was 0% in bDMARD/ts-
DMARD-naïve patients. In 2017, the proportion of patients using non-TNFi increased to 33.8%
among all patients and 33.3% in bDMARD/tsDMARD-naïve patients.
Conclusion: This descriptive analysis of data from the OBRI cohort reveals that TNFi are still
used in the majority of cases; however, there has been an increase in the use of non-TNFi therapies
both overall and as first-line advanced therapy. This trend towards non-TNFi therapies as first-line
advanced therapy may be partially explained by the shift in guideline recommendations from TNFi
as first-line to any of the advanced therapeutics.