1
|
Dong W, Hu X, Wu C, Wang G, Fang Y, Shi L, Nie X. Efficacy, safety, and cost-effectiveness of therapeutic drug monitoring (TDM) for TNF inhibitor therapy in rheumatic disease: A systematic review and meta-analysis. Semin Arthritis Rheum 2023; 63:152302. [PMID: 37951128 DOI: 10.1016/j.semarthrit.2023.152302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 11/13/2023]
Abstract
OBJECTIVE The benefits of TDM-guided TNFi therapy in patients with rheumatic disease was still controversial. This systematic review and meta-analysis was conducted to explore if the TDM-guided TNFi therapy is superior to empirical-guided therapy. METHODS We systematically searched PubMed, Web of Science, Cochrane Library, and EMBASE databases for articles published between database inception and October 05, 2023. Studies reporting endpoints in TDM-guided TNFi therapy and empirical therapy were included. Results would be presented in risk ratio (RR) and mean difference, with 95 % confidence interval (CI) reported. This study is registered with PROSPERO (CRD42022353956). RESULTS A total of 14 studies (eight RCTs and six cohort studies) involving 2427 patients were included in this meta-analysis. In the scenario of response prediction, compared with empirical-guided therapy, TDM-guided TNFi therapy had association with higher treat-to-target rates (RR 1.30, 95 % CI 1.02-1.65, P=0.03, I2=79 %), more specifically, higher low disease activity rates (RR 2.11, 95 % CI 1.22-3.66, P=0.007, I2=61 %), but no difference in clinical remission rates (RR 0.98,95 % CI 0.87-1.11, P=0.75, I2=0 %). In the scenario of dose reduction prediction, lower relapse rates (RR 0.73, 95 % CI 0.65-0.82, P <0.00001, I2=0 %) were observed compared with empirical-guided dose reduction strategy, but no difference (RR 1.24, 95 % CI 0.85-1.80, P=0.27, I2=57 %) between TDM-guided dose reduction and standard-dosing therapy. No significant difference was observed in change of disease activity score, mean disease activity score, radiographic progression, and safety. And TDM-guided therapy was associated with reduced cost per patient per year calculated as the total accumulated sum of therapy cost. CONCLUSION TDM-guided TNFi therapy was associated with increased rates of low disease activity and decreased risks of relapse, and may save cost compared with empirical-guided therapy in patients with rheumatic disease. But this does not mean that the use of TDM-guided TNFi therapy can be advocated, because there is no difference in clinical remission rates and many other outcomes. More researches, especially randomized clinical trials are needed to verify this conclusion in the future.
Collapse
Affiliation(s)
- Wenliang Dong
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China; Clinical Trial Institution, Peking University People's Hospital, Beijing 101109, China
| | - Xiaowen Hu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Caiying Wu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Gengchen Wang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Yi Fang
- Clinical Trial Institution, Peking University People's Hospital, Beijing 101109, China.
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China; International Research Center for Medicinal Administration, Peking University, Beijing 100191, China.
| | - Xiaoyan Nie
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China; International Research Center for Medicinal Administration, Peking University, Beijing 100191, China.
| |
Collapse
|
2
|
Batko B, Batko K, Krzanowski M, Żuber Z. Physician Adherence to Treat-to-Target and Practice Guidelines in Rheumatoid Arthritis. J Clin Med 2019; 8:E1416. [PMID: 31500394 PMCID: PMC6780913 DOI: 10.3390/jcm8091416] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/26/2019] [Accepted: 09/05/2019] [Indexed: 12/15/2022] Open
Abstract
Principles of treat-to-target (T2T) have been widely adopted in both multinational and regional guidelines for rheumatoid arthritis (RA). Several questionnaire studies among physicians and real-world data have suggested that an evidence-practice gap exists in RA management. Investigating physician adherence to T2T, which requires a process measure, is difficult. Different practice patterns among physicians are observed, while adherence to protocolized treatment declines over time. Rheumatologist awareness, agreement, and claims of adherence to T2T guidelines are not always consistent with medical records. Comorbidities, a difficult disease course, communication barriers, and individual preferences may hinder an intensive, proactive treatment stance. Interpreting deviations from protocolized treatment/T2T guidelines requires sufficient clinical context, though higher adherence seems to improve clinical outcomes. Nonmedical constraints in routine care may consist of barriers in healthcare structure and socioeconomic factors. Therefore, strategies to improve the institution of T2T should be tailored to local healthcare. Educational interventions to improve T2T adherence among physicians may show a moderate, although beneficial effect. Meanwhile, a proportion of patients with inadequately controlled RA exists, while management decisions may not be in accordance with T2T. Physicians tend to be aware of current guidelines, but their institution in routine practice seems challenging, which warrants attention and further study.
Collapse
Affiliation(s)
- Bogdan Batko
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski University, Gustawa Herlinga-Grudźińskiego 1 St, 30-705 Cracow, Poland.
- Department of Rheumatology, J. Dietl Specialist Hospital, Skarbowa 1 St, 31-121 Cracow, Poland.
| | - Krzysztof Batko
- Chair and Head of Nephrology, Jagiellonian University Medical College, Kopernika St 15c, 31-501 Cracow, Poland.
| | - Marcin Krzanowski
- Chair and Head of Nephrology, Jagiellonian University Medical College, Kopernika St 15c, 31-501 Cracow, Poland.
| | - Zbigniew Żuber
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski University, Gustawa Herlinga-Grudźińskiego 1 St, 30-705 Cracow, Poland.
- Ward for Older Children with Neurology and Rheumatology Subdivision, St. Louis Regional Specialised Children's Hospital, 31-503 Cracow, Poland.
| |
Collapse
|
3
|
Wabe N, Lee A, Wechalekar M, McWilliams L, Proudman S, Wiese M. Factors associated with medication adherence in a longitudinal study of rheumatoid arthritis patients. Int J Clin Pract 2019; 73:e13375. [PMID: 31120169 DOI: 10.1111/ijcp.13375] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 05/08/2019] [Accepted: 05/20/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Identification of key determinants of medication adherence may assist with designing interventions to improve this important parameter. The aim of the study was to determine the rate and predictors of self-reported medication adherence in patients with rheumatoid arthritis (RA) over one-year follow-up. METHODS Socio-demographic, disease, therapy and patient-related factors were obtained from a longitudinal observational cohort of RA patients between May 2014 and June 2016. Medication adherence was measured using self-reported Compliance Questionnaire for Rheumatology (CQR) at baseline, 6 and 12 months. Mixed-effects modelling was used to investigate the relationship between adherence and potential predictors. RESULT Of 185 patients invited, 110 were included in the study. The median level of adherence was 71%-74% during the study period. Around 27%-30% of patients achieved > 80% adherence, while roughly one-fifth reported a CQR score within the lower quartile (CQR < 63%). After adjustment for potential confounders, increased age (β = 0.19, P = 0.010), higher self-efficacy (β = 0.89, P = 0.039) and higher medication necessity belief (β = 1.12, P < 0.0001) were associated with better self-reported adherence. CONCLUSION We found a moderate level of self-reported adherence over time and significant association with age, self-efficacy and medication necessity belief. The modifiable predictors of adherence found in this study can be used as a potential target for adherence-improving interventions.
Collapse
Affiliation(s)
- Nasir Wabe
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW, Australia
| | - Anita Lee
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Mihir Wechalekar
- School of Medicine, Flinders University, Adelaide, SA, Australia
- Rheumatology Unit, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Leah McWilliams
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Michael Wiese
- School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| |
Collapse
|
4
|
What is the optimal target for treat-to-target strategies in rheumatoid arthritis? Curr Opin Rheumatol 2018; 30:282-287. [DOI: 10.1097/bor.0000000000000484] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
|
5
|
Wabe N, Wojciechowski J, Wechalekar MD, Cleland LG, McWilliams L, Lee A, Proudman S, Wiese MD. Disease activity trajectories in early rheumatoid arthritis following intensive DMARD therapy over 3 years: association with persistence to therapy. Int J Rheum Dis 2017; 20:1447-1456. [PMID: 28952204 DOI: 10.1111/1756-185x.13184] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To identify the disease activity trajectories during intensive triple disease modifying anti-rheumatic drug (DMARD) therapy over 3 years in rheumatoid arthritis (RA) patients and to evaluate the association with treatment persistence. METHODS Disease Activity Score in 28 joints, baseline risk factors and medication usage were obtained from a longitudinal observational cohort of early RA patients, most of whom were treated with combination DMARD therapy consisting of methotrexate, sulfasalazine and hydroxychloroquine. Persistence of each DMARD was defined as the duration of time from initiation to cessation. A group-based trajectory modelling technique was used to identify disease activity trajectories. RESULT Three disease activity trajectories (good [43.8%], moderate [39.7%] and poor [16.5%]) were identified in a cohort of 297 patients. Most baseline risk factors, medication usage, the rate of treatment persistence and the effect of persistence on disease activity differed among patients in each of the three trajectories. Although the rate of persistence was higher in the trajectory with a good outcome, the association with persistence was more pronounced among patients who were in the poor outcome trajectory. Persistence with at least two or all three baseline DMARDs was associated with a decrease in disease activity to a broadly similar degree in all trajectories. CONCLUSION After correction for other baseline prognostic factors, persistence with initial DMARDs contributes to heterogeneity in disease activity trajectory and there was an association between persistence with initial DMARD therapy and lower long-term disease activity.
Collapse
Affiliation(s)
- Nasir Wabe
- School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, Adelaide, South Australia, Australia
| | - Jessica Wojciechowski
- School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, Adelaide, South Australia, Australia.,Australian Centre for Pharmacometrics, University of South Australia, Adelaide, South Australia, Australia
| | - Mihir D Wechalekar
- Rheumatology Unit, Repatriation General Hospital, Adelaide, South Australia, Australia
| | - Leslie G Cleland
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Leah McWilliams
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Anita Lee
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michael D Wiese
- School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, Adelaide, South Australia, Australia
| |
Collapse
|
6
|
Adherence to combination DMARD therapy and treatment outcomes in rheumatoid arthritis: a longitudinal study of new and existing DMARD users. Rheumatol Int 2017; 37:897-904. [PMID: 28160071 DOI: 10.1007/s00296-017-3655-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
Abstract
Medication adherence is believed to be a major contributor to treatment outcomes yet studies quantifying this relationship as rare in rheumatoid arthritis (RA). To determine the association of adherence to DMARD therapy with treatment outcomes among new and existing DMARD users over 2 years. Relevant clinical parameters were obtained from a longitudinal cohort of RA patients, most of who were treated with combination therapy. Patients were classified as adherent if the proportion of days covered for each DMARD was ≥80%. Outcome measures were the change in the disease activity score in 28 joints (DAS28), simplified disease activity index (SDAI), modified health assessment questionnaires (mHAQ) and proportion of patients who achieved response criteria. An inverse propensity-score weighting method was used to estimate the association of adherence with each outcome. Of 194 patients invited, a total of 111 patients (new = 45 and existing = 66 DMARD users) met study eligibility. DMARD-naive patients demonstrated relatively higher rates of adherence compared to existing users. After controlling for confounding variables, adherence was significantly associated with reduction in DAS28 (β = -1.5, 95% CI of β = - 2.17 to -0.83, p < 0.0001), SDAI (β = -9.44, 95% CI of β = -15.53 to -3.35, p = 0.002) and mHAQ (β = -0.269, 95% CI of β, -0.462 to -0.077, p = 0.017) over 2 years among new patients and adherent patients were more likely to achieve most response criteria compared to non-adherent patients. Such associations were not replicated among existing DMARD users. Adherence to combination DMARD therapy was associated with improvements in disease activity and functional outcomes in the first 2 years of therapy.
Collapse
|
7
|
Wabe NT, Sorich MJ, Wechalekar MD, Cleland LG, McWilliams L, Lee AT, Spargo LD, Metcalf RG, Hall C, Proudman SM, Wiese MD. Effect of Adherence to Protocolized Targeted Intensifications of Disease-modifying Antirheumatic Drugs on Treatment Outcomes in Rheumatoid Arthritis: Results from an Australian Early Arthritis Cohort. J Rheumatol 2016; 43:1643-9. [DOI: 10.3899/jrheum.151392] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 11/22/2022]
Abstract
Objective.To investigate the association between adherence to treat-to-target (T2T) protocol and disease activity, functional outcomes, and radiographic outcomes in early rheumatoid arthritis (RA).Methods.Data from a longitudinal cohort of patients with early RA were used. Adherence was determined at each followup visit over 3 years according to predefined criteria. The primary endpoint was remission according to Disease Activity Score in 28 joints (DAS28) and Simplified Disease Activity Index (SDAI) criteria. Functional and radiographic outcomes measured by modified Health Assessment Questionnaire and modified total Sharp score, respectively, were secondary endpoints.Results.A total of 198 patients with 3078 clinic visits over 3 years were included in this analysis. After adjusting for relevant variables, although there was no significant association between adherence to T2T and remission rate after 1 year, the associations reached significance after 3 years for both DAS28 (OR 1.71, 95% CI 1.16–2.50; p = 0.006) and SDAI criteria (OR 1.94, 95% CI 1.06–3.56; p = 0.033). After 3 years, adherence was also associated with improvement in physical function (β=0.12, 95% CI 0.06–0.18; p < 0.0001). None of the radiographic outcomes were associated with adherence after either 1 or 3 years, although there was a trend for higher adherence to be associated with less radiographic progression at the end of the study (p = 0.061).Conclusion.Increased adherence to T2T was associated with better longterm disease activity and functional outcomes, which suggests that the benefit of a T2T protocol may be enhanced by ensuring adequate adherence.
Collapse
|