Rheumatoid Arthritis Treatment with Biologic Agents

Rationale for Non-Approval

The American College of Rheumatology recommends that patients with rheumatoid arthritis should not receive concurrent treatment with multiple biologic agents, as it increases the risk of serious infections and other adverse events without providing additional clinical benefit 2
Aetna CPB 0314 states that members will not receive Rituxan, Ruxience, Truxima, or Riabni with any other biologic drug or targeted synthetic drug for RA, due to the increased risk of adverse events 1

Patients with rheumatoid arthritis who have been treated with multiple agents, including methotrexate, Humira (adalimumab), and plaquenil, may be considered for treatment with rituximab if they have an inadequate response to one or more TNF inhibitors 2

The standard approach for rheumatoid arthritis treatment follows a sequential pattern, where patients who have an inadequate response to one TNF inhibitor may be switched to a different mechanism of action, such as rituximab, but not concurrently 2
When switching from infliximab to rituximab, the current biologic (infliximab) should be discontinued before initiating the new biologic, to minimize the risk of adverse events 1

Rituximab is indicated for RA patients with inadequate response to one or more TNF inhibitors, but only after discontinuation of the previous biologic, and the standard dosing is 1000 mg IV given twice, two weeks apart, with subsequent courses administered no sooner than every 16 weeks 1

If a patient is not responding adequately to infliximab, the appropriate approach would be to discontinue infliximab completely, and after an appropriate washout period, initiate rituximab as monotherapy or in combination with methotrexate, with standard rituximab dosing: 1000 mg IV every 2 weeks for 2 doses, with subsequent courses based on clinical evaluation but no sooner than every 16 weeks 1