The biologic disease modifying anti-rheumatic drug (bDMARD) choosen for  rheumatoid arthritis (RA) is mainly dependent on the clinician’s preference as mentioned in the international recommendations. The real-life factors influencing the first-line choice or the switching strategy were investigated were investigated which pivoted on the prescription of abatacept (ABA) or tocilizumab (TCZ) compared to TNFα inhibitors (TNFi).

A total of 1910 patients registered  in the Lombardy Rheumatology Network (LORHEN) Registry after January 1, 2010 were included when all considered bDMARD agents were available. The population was classified into “first-” (n = 1264 ) and “second-line” ( n = 646) bDMARD. Age was higher in ABA or TCZ vs TNFi treated patients (p < 0.0001). Positive latent tuberculosis screening was concerned with first-line ABA (p = 0.002). In the TCZ group (p = 0.02), methotrexate (MTX) combination therapy was lower. The choice towards ABA (p = 0.01) was motivated by the type (dyslipidemia, hypertension, pulmonary disease) and the number of comorbidities.

Second-line treatment, higher age, dyslipidemia, pulmonary disease, other comorbidities, and extra-articular RA manifestations were concerned with ABA compared to TNFi as revealed by the multinomial logistic regression. TCZ was concerned with a second-line treatment, higher age, and more severe disease activity. The choice towards ABA was influenced by hindering the first bDMARD due to adverse events (AE). Higher age and comorbidities affect the choice towards ABA and TCZ as compared to TNFi in the real life. In case of suspension of earlier treatments due to AE, ABA was considered. After failing a first-line TNFi, switching to a distinct mechanism of action is more frequent.