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Comparative effectiveness of treatment options after conventional DMARDs failure in rheumatoid arthritis



To compare the clinical effectiveness of two treatment strategies for active rheumatoid arthritis (RA) refractory to conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs): starting TNF inhibitors (TNFIs) or changing csDMARDs.


We used two nationwide Korean RA registries for patient selection. TNFI users were selected from the BIOPSY, which is an inception cohort of RA patients starting biologic DMARDs. As a control group, we selected RA patients with moderate or high disease activity from the KORONA database whose treatment was changed to other csDMARDs. After comparing baseline characteristics between the two groups in either unmatched or propensity score matched cohorts, we compared potential differences in the 1-year remission rate as a primary outcome and changes in HAQ-DI and EQ-5D scores as secondary outcomes.


A total of 356 TNFI starters and 586 csDMARD changers were identified from each registry as unmatched cohorts, and 294 patients were included in the propensity score matched cohort. In the intention-to-treat analysis, TNFI starters had higher 1-year remission rates than csDMARD changers in both unmatched (19.1 vs. 18.4%, p < 0.01) and matched cohorts (19.7 vs. 15.0%, p < 0.01). In per protocol analysis, TNFI starters had much higher remission rates in unmatched (37.2 vs. 28.0%, p = 0.04) and matched cohorts (35.4 vs. 19.1%, p = 0.04). However, in matched cohorts, no significant differences were observed between two groups in HAQ-DI and EQ-5D scores.


We compared the clinical effectiveness of the two treatment strategies for active RA refractory to csDMARDs. TNFI starters showed higher 1-year remission rates than csDMARD changers.

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The authors wish to acknowledge the assistance of the following investigators who have enrolled patients to KORONA: Drs. Joong Kyong Ahn, Minyoung Her, Yun Kyung Hong, Chung-Il Joung, Young Ok Jung, Young Mo Kang, Dong-Yook Kim, Hae-Rim Kim, Sung-Il Kim, Tae-Jong Kim, Eunmi Koh, Choong Ki Lee, Sang-Heon Lee, Sang-Hoon Lee, So-Yeon Park, Sung-Hoon Park, Dong Hyuk Sheen, Jeeseon Shim Seung-Cheol Shim, Gwan Gyu Song, Wan-Sik Uhm, and Wan-Hee Yoo.

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Correspondence to Sang Cheol Bae.

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This study was approved by the Institutional Review Board of Hanyang University Hospital (HYUH IRB 2009-04-003). All participants provided informed consent under a protocol approved by the Institutional Review Board.

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All authors have no conflicts of interest to disclose.


This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health and Welfare, Republic of Korea (Grant Number : HI16C0061).

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Sung, YK., Cho, SK., Kim, D. et al. Comparative effectiveness of treatment options after conventional DMARDs failure in rheumatoid arthritis. Rheumatol Int 37, 975–982 (2017).

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  • Rheumatoid arthritis
  • DMARDs
  • Anti-TNF drugs
  • HAQ
  • Quality of life