Effectiveness and treatment retention of TNF inhibitors when used as monotherapy versus comedication with csDMARDs in 15 332 patients with psoriatic arthritis. Data from the EuroSpA collaboration

Ulf Lindström*, Daniela Di Giuseppe, Bénédicte Delcoigne, Bente Glintborg, Burkhard Möller, Adrian Ciurea, Manuel Pombo-Suarez, Carlos Sanchez-Piedra, Kari Eklund, Heikki Relas, Bjorn Gudbjornsson, Thorvardur Jon Love, Gareth T. Jones, Catalin Codreanu, Ruxandra Ionescu, Lucie Nekvindova, Jakub Závada, Nuh Atas, Servet Yolbas, Karen Minde FagerliBrigitte Michelsen, Rotar, Matija Tomšič, Florenzo Iannone, Maria Jose Santos, Pedro Avila-Ribeiro, Lykke Midtbøll Ørnbjerg, Mikkel Østergaard, Lennart T.H. Jacobsson, Johan Askling, Michael J. Nissen

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

20 Citations (Scopus)
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Background: Comedication with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) during treatment with tumour necrosis factor inhibitors (TNFi) is extensively used in psoriatic arthritis (PsA), although the additive benefit remains unclear. We aimed to compare treatment outcomes in patients with PsA treated with TNFi and csDMARD comedication versus TNFi monotherapy. Methods: Patients with PsA from 13 European countries who initiated a first TNFi in 2006-2017 were included. Country-specific comparisons of 1 year TNFi retention were performed by csDMARD comedication status, together with HRs for TNFi discontinuation (comedication vs monotherapy), adjusted for age, sex, calendar year, disease duration and Disease Activity Score with 28 joints (DAS28). Adjusted ORs of clinical remission (based on DAS28) at 12 months were calculated. Between-country heterogeneity was assessed using random-effect meta-analyses, combined results were presented when heterogeneity was not significant. Secondary analyses stratified according to TNFi subtype (adalimumab/infliximab/etanercept) and restricted to methotrexate as comedication were performed. Results: In total, 15 332 patients were included (62% comedication, 38% monotherapy). TNFi retention varied across countries, with significant heterogeneity precluding a combined estimate. Comedication was associated with better remission rates, pooled OR 1.25 (1.12-1.41). Methotrexate comedication was associated with improved remission for adalimumab (OR 1.45 (1.23-1.72)) and infliximab (OR 1.55 (1.21-1.98)) and improved retention for infliximab. No effect of comedication was demonstrated for etanercept. Conclusion: This large observational study suggests that, as used in clinical practice, csDMARD and TNFi comedication are associated with improved remission rates, and specifically, comedication with methotrexate increases remission rates for both adalimumab and infliximab.

Original languageEnglish
Article number220097
Pages (from-to)1410-1418
Number of pages9
JournalAnnals of the Rheumatic Diseases
Issue number11
Early online date3 Jun 2021
Publication statusPublished - Nov 2021

Bibliographical note

Funding This work was supported by Novartis. Novartis had no influence on the data collection, statistical analyses, manuscript preparation or decision to submit. The work was also supported by NordForsk


  • arthritis
  • methotrexate
  • psoriatic
  • tumour necrosis factor inhibitors


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