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Objectives  The aim was to define sub-optimal response to TNF inhibitors (TNFi), compare long-term drug survival rates and identify predictors of sub-optimal response in axial spondyloarthritis (axSpA) patients in a UK cohort.    Methods  All axSpA patients attending two centres who commenced TNFi between 2002 and 2016 were included. Routinely recorded patient data were reviewed retrospectively. Patients with paired BASDAI at baseline, 3 and/or 6 months were included for analysis. Sub-optimal response was defined as achieving a ≥ 2-point reduction in BASDAI but not BASDAI50, post-treatment BASDAI remaining at ≥4, and in the opinion of the treating physician these patients demonstrated a meaningful clinical response.    Results  Four hundred and ninety-nine patients were included: 82 (16.4%) patients were classified as having a sub-optimal response; 64 (78%) males, 78 (95.1%) AS and 55/67 (82.1%) HLA-B27 positive. Results are reported as the mean ( s . d .). Time to diagnosis was 10 (8.6) years, age at diagnosis was 37 (11.7) years, and age at initiating index TNFi was 48 (11.1) years. Individual index TNFi were Humira (adalimumab,  n  = 41, 50%), Enbrel (etanercept,  n  = 27, 32.9%), Remicade (infliximab,  n  = 5, 6.1%), Simponi (golimumab,  n  = 3, 3.7%) and Cimzia (certolizumab pegol,  n  = 6, 7.3%). The rate of attrition was greater among sub-optimal responders at 2 and 5 years ( P  < 0.05), but not at 10 years ( P  = 0.06), compared with responders. Older age at initiation of TNFi was a predictor of sub-optimal response (odds ratio 1.04, 95% CI 1.01, 1.09,  P  < 0.05).    Conclusion  A significant proportion of patients continued TNFi despite demonstrated sub-optimal response. Further research needs to be undertaken in order to understand this group.

Exploring sub-optimal response to tumour necrosis factor inhibitors in axial spondyloarthritis