Comparative Effectiveness of Abatacept versus Adalimumab in Shared Epitope positive and negative Rheumatoid Arthritis patients

Objectives The effect of the shared epitope (SE), and valine at position 11 (Val11) of HLA-DRB1, on the activation of CD4+ T cells, is expected to be diminished by abatacept, a co-stimulation blocker. However, published evidence on the value of genetic stratification for abatacept treatment is conflicting. We aimed to compare the difference in effectiveness of abatacept and adalimumab in patients carrying the SE (or Val11).

Methods The Biologics in Rheumatoid Arthritis Genetics and Genomics Study Syndicate is a nationwide observational cohort study recruiting patients from 53 centres across the UK before the initiation of biologic treatment and following them up prospectively for 12 months. 342 patients starting either on abatacept or adalimumab were eligible for this analysis. Serum drug levels for abatacept, adalimumab and methotrexate were determined at multiple time points. Multivariate modelling integrating demographic, clinical and pharmacological variables was used to test for associations between the number of copies of the SE or Val11 with response to treatment (EULAR response; DAS28 remission; change in DAS28). Differential effectiveness between drugs and genetic markers was assessed by the significance of their interaction term.

Results There was no difference in the efficacy of abatacept versus adalimumab. We found weak evidence for an independent association of genetic markers with response to treatment (Val11 with EULAR response: p-value=0.02), but there was no significant difference in this effect between drugs.

Conclusions We find no evidence that HLA-typing is clinically useful to support prescription decisions for these two drugs.