FormalPara Key Points

Administration of subcutaneous golimumab (GLM-SC) at 4- and 8-week intervals after switching from TNF inhibitors resulted in sustained efficacy and acceptable safety in rheumatoid arthritis patients with low disease activity.

Long-term GLM-SC treatment efficacy and safety were successfully maintained despite a long interval.

1 Introduction

The treatment of rheumatoid arthritis (RA) is predominantly focused on controlling inflammation and pain, as well as slowing the progression of joint destruction and disability. The development of biologic disease-modifying anti-rheumatic drugs (DMARDs) represents a major breakthrough in the treatment of RA. These drugs could help achieve low disease activity (LDA) or even remission in patients with moderate-to-severe RA [1, 2].

Tumor necrosis factor (TNF)-α inhibitors tend to be the first agents prescribed when biologic DMARDs are indicated in RA, due to the wealth of evidence, experience, and long-term follow-up data. Although the efficacy of TNF-α inhibitors as treatments for patients with active RA has been widely demonstrated, some RA patients show decreased responsiveness after initially responding well to treatment. One of the potential reasons for the lack or loss of efficacy of the TNF inhibitors over time is the immunogenicity associated with biologic DMARDs. Thus, in such cases, it is useful to switch to a less immunogenic biologic agent to maintain disease activity and minimize adverse events [3].

Golimumab (GLM) is less immunogenic compared with the other TNF inhibitors used for RA treatment [4]. Our previous study indicated a prolonged effect and improvement similar to that associated with infliximab (IFX) after switching to subcutaneous GLM (GLM-SC) for control of disease activity or adverse events [5]. In patients with RA, the overall treatment satisfaction could be influenced by factors associated with the application of the biologic agent used, such as the route, timing, and frequency of administration. GLM-SC is convenient compared with intravenous infusion of TNF inhibitors and requires fewer injections compared with etanercept (ETN; 50 mg once weekly or 25 mg twice weekly). The purpose of this study was to evaluate continued maintenance of long-term treatment effectiveness and safety on switching to GLM-SC in RA patients with LDA or in remission who previously received another TNF inhibitor.

2 Patients and Methods

2.1 Patients and Golimumab Therapy Protocol

This was a simple observational study performed among 32 patients (25 female and 7 male patients) in whom treatment was switched to GLM-SC from other TNF inhibitors so as to ensure continuous LDA at Mie University and two other institutes.

The patients were divided into two dosing interval groups, as described previously [5]. At our center, the decision on the interval was made by the treating physician through a discussion with each patient, considering the patient’s general condition and convenience. The GLMq4w group included 17 patients with LDA or in remission who switched to 50-mg GLM therapy at 4-week intervals and received methotrexate (MTX) concomitantly. The GLMq8w group included 15 patients with LDA or in remission who switched to 50-mg GLM therapy at 8-week intervals and received MTX concomitantly. In the GLMq4w group, 15 patients switched from IFX (200–300 mg/8 weeks) and two patients switched from ETN to GLM, while in the GLMq8w group, 14 patients switched from IFX and one patient switched from ETN. The ethics committee of Mie University approved this study (approval number: 2120).

2.2 Clinical Assessment

The follow-up assessment included observation of signs and symptoms and determination of the disease activity score (DAS) as described previously [5]. DAS28-erythrocyte sedimentation rate (ESR) [6] and DAS-C reactive protein (CRP) [7] were used to evaluate RA disease activity at 104 weeks and the latest follow-up compared with that at baseline. GLM continuation rates at 104 weeks and > 104 weeks (the latest follow-up) were also examined. For the safety evaluation, we assessed adverse events and serious adverse events leading to treatment discontinuation in each group. If patients discontinued GLM treatment before week 104, their data were analyzed by the last-observation-carried-forward method. The dose of concomitant MTX remained basically consistent; however, tapering of non-steroidal anti-inflammatory drugs and glucocorticoids was allowed during the study period.

2.3 Statistical Analysis

Differences between the groups in terms of swollen and tender joint counts, patient global assessment, ESR, CRP, and DAS28-ESR and DAS-CRP scores were determined using the Wilcoxon rank-sum test, analysis of variance, Pearson’s test, or the Tukey–Kramer honestly significant difference test. Survival distribution curves were computed by the Kaplan–Meier method. A p value < 0.05 was considered statistically significant. All statistical analyses were performed using IBM SPSS Statistics 26 (IBM Japan, Tokyo, Japan).

3 Results

3.1 Patients’ Characteristics

The patients’ mean age was 63.9 years (range 42–80) at the start of GLM treatment. Table 1 shows the baseline characteristics of the patients. The percentage of patients who received corticosteroids in the GLMq4w group was significantly lower than that in the GLMq8w group (p < 0.05) (Table 1). In the GLMq8w group, RA duration was significantly shorter than that in the GLMq4w group (p = 0.01). However, intergroup differences in serum markers or disease activity at baseline were not significant.

Table 1 Patients’ characteristics
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3.2 Efficacy, Adverse Events, and Survival Analyses

The mean DAS28-ESR and DAS28-CRP values in the GLMq4w and GLMq8w groups were maintained from baseline throughout the 104-week treatment period (Fig. 1a,b). In the GLMq4w and GLMq8w groups, respectively, DAS28-ESR remission (< 2.6) rates (58.8% and 73.3%) and LDA (< 3.2) rates (88.2% and 100%), and DAS28-CRP remission (< 2.3) rates (88.2% and 86.7%) and LDA (< 2.7) rates (88.2% and 100%) were also maintained at week 104 (Fig. 1c,d). The disease activity increased to a moderate level in two patients in the GLMq4w group. One patient was transferred to another hospital while continuing GLM treatment, and the GLM dose was increased to 100 mg once every 4 weeks for the other patient.

Fig. 1
figure 1

Changes in measured disease activity (a DAS28-ESR; b DAS28-CRP), rates of remission, and low and moderate disease activity (c DAS28-ESR; d DAS28-CRP) before treatment and at weeks 12, 24, 52, and 104, and at the latest follow-up in each group. Overall disease control was maintained after switching from infliximab or etanercept to subcutaneous golimumab in both groups. LF latest follow up, DAS28 disease activity score 28, ESR erythrocyte sedimentation rate, CRP C-reactive protein

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Adverse events through week 104 of this study are shown in Table 2. Infections were the most reported adverse events across both treatment groups, occurring in 23.5% and 20% of patients in the GLMq4w and GLMq8w groups, respectively. The incidence of infections was, thus, the same in both groups. No serious adverse event or injection-site reaction occurred, and the treatment continuation rate at 104 weeks was 100% in both groups.

Table 2 Adverse events through 2 years of GLM treatment
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After > 2 years (104 weeks) of treatment, the DAS28-ESR LDA rates (88.2% and 93.3%) and DAS28-CRP LDA rates (88.2% and 86.7%) were also maintained at the latest follow-up in the GLMq4w and GLMq8w groups, respectively (Fig. 1c, d). However, one patient in the GLMq8w group discontinued GLM treatment due to relapse to moderate disease. Furthermore, one patient (uterine cancer) in the GLMq4w group and two patients (MTX-related lymphoproliferative disorder and postoperative infection in the spine) in the GLMq8w group discontinued GLM treatment due to complications. The 5-year survival rates associated with GLM continuation in the GLMq4w and GLMq8w groups were 88.2% and 75.5%, respectively (Fig. 2). The average treatment duration was 5.0 (2.0–7.5) years.

Fig. 2
figure 2

Survival rates associated with the continuation of golimumab treatment

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4 Discussion

Biologic medications such as subcutaneous TNF-α inhibitors (SC-TNFis) have transformed the management of diseases [8]. Furthermore, the administration of biologic medications with higher persistence rates is beneficial for maintaining disease activity in patients. The availability of biologic agents specifically for RA has expanded treatment options in terms of route and timing of administration as well as the range of possible toxicities and cost of therapy [9]. Treatments with biologics may or may not include an induction period and the administration could range from twice a week to once every 8 weeks. These factors can influence patients’ overall satisfaction with their treatment, because the mode and frequency of treatment administration are important to patients with RA.

GLM-SC was associated with a better treatment effect and survival rate than were other TNF inhibitors [10,11,12]. These reports support the notion that GLM may have better real-world persistence of the treatment effect. In vitro bioassays showed that the affinity of GLM for soluble TNFα and its ability to neutralize it were similar to those of ETN and greater than those of IFX and adalimumab (ADA). These results suggest that a lower serum concentration of GLM, compared with that of IFX or ADA, would have similar pharmacological effects in patients [13].

In our previous study, among patients with RA whose treatment was switched from IFX or ETN to GLM-SC 50 mg every 4 or 8 weeks, clinical improvement continued from week 0 to week 52 of the study [14]. Here, we report the results from the second year of treatment. Both GLM-SC treatment regimens with 4- and 8-week intervals secondary to TNF inhibitors were effective in maintaining the clinical response achieved with LDA. Furthermore, the continuation rate of GLM treatment at 2 years was 100% in both groups. The 5-year survival rates associated with the continuation of GLM treatment were 88.2% and 75.5% in the GLMq4w and GLMq8w groups, respectively.

GLM has been developed with an innovative technology that minimizes immunogenicity [4, 15]. In recent studies, the 2-year survival associated with GLM treatment was 51.9–73.1% among those whose response to biologics was inadequate and in biologic-naive patients [16, 17]. Gomides et al. reported that GLM was associated with fewer episodes of discontinuation due to secondary inefficiency [18]. This result may be due to the low immunogenicity of GLM. The prescribing information for GLM-IV specifies a dosing regimen of 2 mg/kg at maintenance therapy every 8 weeks thereafter. GLM can be administered by subcutaneous injection as well as by intravenous infusion. GLM-SC is the only biologic agent approved for the treatment of RA in Japan. In our study, one of the reasons for the continued maintenance of disease activity even with an 8-week interval between consecutive GLM doses may be that this dose interval results in less immunogenicity. For other reasons, in the GO-SAVE trial, most patients with RA who transitioned to GLM from ADA or ETN were satisfied with their overall GLM experience. Patients who received GLM-SC through week 44 reported much less discomfort, redness, pain, stinging, and burning with the GLM injection than with their previous injections with TNF inhibitors [19]. Bolge et al. reported that injection experience is an often-cited reason for the discontinuation of anti-TNF medication by patients with RA [20]. The less severe injection-site reaction and the longer administration interval may have contributed to the treatment continuation rate.

Our data suggest that a shorter disease duration enables successful maintenance of GLM treatment despite a long interval between doses. In previous reports, the predictors of GLM discontinuation in patients were female sex, GLM monotherapy [16, 17], and failing to early achievement of a good European League Against Rheumatism (EULAR) response in RA [17]. Another reason for the good treatment continuation rate in the GLMq8w group in this study could be that the MTX use rate was 100% and that there were many male patients. In addition, the reason the continuation rate was good in both groups was the possibility of switching in case of LDA, which seems to be effective in maintaining disease activity.

The key limitations of this study are the smaller number of patients who received open-label GLM-SC. Furthermore, radiographic data were lacking, leading to the possibility that some patients may have had residual disease activity and consequent structural damage. We think that such effects were at best small, if they existed, because of LDA maintenance.

5 Conclusion

Long-term administration of GLM-SC was associated with continuing efficacy in patients with RA. GLM-SC was well tolerated and LDA was maintained in both the GLMq4w and GLMq8w groups, with no new safety concerns identified.