OBJECTIVE: To provide real-world evidence about the reasons why Australian 
rheumatologists cease biologic (b) and targeted synthetic (ts) disease-modifying 
antirheumatic drugs (DMARD) when treating patients with rheumatoid arthritis 
(RA), and to assess (1) the primary failure rate for first-line treatment, and 
(2) the persistence on second-line treatments in patients who stopped first-line 
tumor necrosis factor inhibitors (TNFi).
METHODS: This is a multicenter retrospective, noninterventional study of 
patients with RA enrolled in the Australian Optimising Patient outcome in 
Australian RheumatoLogy (OPAL) dataset with a start date of b/tsDMARD between 
August 1, 2010, and June 30, 2017. Primary failure was defined as stopping 
treatment within 6 months of treatment initiation.
RESULTS: Data from 7740 patients were analyzed; 6914 patients received 
first-line b/tsDMARD. First-line treatment was stopped in 3383 (49%) patients; 
1263 (37%) were classified as primary failures. The most common reason was "lack 
of efficacy" (947/2656, 36%). Of the patients who stopped first-line TNFi, 43% 
(1111/2560) received second-line TNFi, which resulted in the shortest median 
time to stopping second-line treatment (11 months, 95% CI 9-12) compared with 
non-TNFi. The longest second-line median treatment duration after first-line 
TNFi was for patients receiving rituximab (39 months, 95% CI 27-74).
CONCLUSION: A large proportion of patients who stopped first-line TNFi therapy 
received another TNFi despite evidence for longer treatment persistence on 
second-line b/tsDMARD with a different mode of action. Lack of efficacy was 
recorded as the most common reason for making a switch in first-line treatment 
of patients with RA.