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George MD, Baker JF, Ogdie A. Comparative persistence on methotrexate and TNF inhibitors in rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. The Journal of rheumatology. 2019 Sep 1.
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Abstract: OBJECTIVE: The role of methotrexate for the treatment of spondyloarthritis remains uncertain. Aims were to compare methotrexate and tumor necrosis factor inhibitor (TNFi) persistence in spondyloarthritis vs. RA and to determine whether concomitant conventional synthetic DMARD (csDMARD) use is associated with improved TNFi persistence in spondyloarthritis. METHODS: This retrospective cohort study using Optum's de-identified Clinformatics® Data Mart Database 2000-2014 identified patients with RA, psoriatic arthritis (PsA), and ankylosing spondylitis (SpA) without prior biologic use initiating methotrexate or a TNFi for the first time. Cox proportional hazards models compared time to medication discontinuation over the next two years between patients with RA, PsA, or AS, adjusting for potential confounders. In similar analyses stratified by disease, Cox models were used to assess whether concomitant use of csDMARDs was associated with TNFi persistence. RESULTS: We identified 31,527 methotrexate initiators (26,708 RA, 2,939 PsA, 1,880 AS) and 34,651 TNFi initiators (24,134 RA, 6,705 PsA, 3,812 AS). Methotrexate was discontinued sooner in patients with PsA [aHR 1.10 (1.04-1.16)] and AS [aHR 1.23 (1.16- 1.31)] vs. RA, while TNFi were discontinued at similar rates in RA and AS and discontinued later in PsA [aHR 0.93 (0.89-0.97)]. Concomitant use of methotrexate (compared to no csDMARD) was associated with lower rates of TNFi discontinuation in RA [aHR 0.85 (0.80-0.89)], PsA [aHR 0.81 (0.74-0.89)], and AS [aHR 0.79 (0.67-0.93]. CONCLUSION: Methotrexate discontinuation occurs sooner in patients with PsA and AS vs. RA. Concomitant use of methotrexate with a TNFi, however, is associated with improved TNFi persistence in all three diseases.

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