The perplexity of prescribing and switching of biologic drugs in rheumatoid arthritis: a UK regional audit of practice

Real-Life Retention Rates and Reasons for Switching of Biological DMARDs in Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis

Aims: To determine real-life biologic/targeted synthetic disease-modifying anti-rheumatic drug (b/tsDMARD) retention rates in rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS), explore reasons for switching and to compare results to previously published data.

Methods: Time-to-event analysis for mean treatment duration (estimated as the Restricted Mean Survival Time), b/tsDMARD failure, and b/tsDMARDs switching was performed for 230 patients (n = 147 RA, 46 PsA, 37 AS) who commenced their first b/tsDMARD between 2008 and 2018. Patients were managed in a dedicated “biologics” clinic in a tertiary hospital; the choice of b/tsDMARD was clinician driven based on medical factors and patient preferences. The effect of covariates on switching risk was analysed by a conditional risk-set Cox proportional-hazards model. Treatment retention data was compared to a historical analysis (2002–2008).

Results: The proportions remaining on treatment (retention) were similar, throughout follow-up, for the first, second and third b/tsDMARDs across all patients (p = 0.46). When compared to RA patients, the risk of b/tsDMARD failure was halved in PsA patients [Hazard Ratio (HR) = 0.50], but no different in AS patients (HR = 1.0). The respective restricted mean (95%CI) treatment durations, estimated at 5 years of follow-up, were 3.1 (2.9, 3.4), 4.1 (3.7, 4.6), and 3.3 (2.8, 3.9) years, for RA, PsA, and AS, respectively. Age, gender, disease duration, smoking status and the use of concomitant csDMARDS were not associated with the risk of bDMARD failure. The most common reasons for switching in the first and subsequent years were secondary (n = 62) and primary (n = 35) failure. Comparison with historical data indicated no substantive differences in switching of the first biologic for RA and PsA.

Conclusion: Similar retention rates of the second and third compared to the first b/tsDMARD in RA, PsA, and AS support a strategy of differential b/tsDMARDs use informed by patient presentation. Despite greater availability of b/tsDMARDs with differing mechanisms of action, retention rates of the first b/tsDMARD remain similar to previous years.

Factors that influence rheumatologists' anti-tumor necrosis factor alpha prescribing decisions: a qualitative study

Background

Treatment decisions for any disease are usually informed by reference to published clinical guidelines or recommendations. These recommendations can be developed to improve the relative cost-effectiveness of health care and to reduce regional variation in clinical practice. Anti-tumor necrosis factor alpha (anti-TNF) treatments are prescribed for people with rheumatoid arthritis according to specific recommendations by the National Institute for Health and Care Excellence in England. Evidence of regional variation in clinical practice for rheumatoid arthritis may indicate that different factors have an influence on routine prescribing decisions. The aim of this study was to understand the factors that influence rheumatologists’ decisions when prescribing anti-TNF treatments for people with rheumatoid arthritis in England.

Methods

Semi-structured one-to-one telephone interviews were performed with senior rheumatologists in different regions across England. The interview schedule addressed recommendations by the National Institute for Health and Care Excellence, prescribing behavior, and perceptions of anti-TNF treatments. Interviews were recorded digitally, transcribed verbatim, and anonymized. Data were analyzed by thematic framework analysis that comprised six stages (familiarization; coding; developing the framework; applying the framework; generating the matrix; interpretation).

Results

Eleven rheumatologists (regional distribution - north 36%; midlands: 36%; south: 27%) participated (response rate: 24% of the sampling frame). The mean duration of the interviews was thirty minutes (range: 16 to 56 min). Thirteen factors that influenced anti-TNF prescribing decisions were categorized by three nested primary themes; specific influences were defined as subthemes: (i) External Environment Influences (National Institute for Health and Care Excellence Recommendations; Clinical Commissioning Groups; Cost Pressures; Published Clinical Evidence; Colleagues in Different Hospitals; Pharmaceutical Industry); (ii) Internal Hospital Influences (Systems to Promote Compliance with Clinical Recommendations; Internal Treatment Pathways; Hospital Culture); (iii) Individual-level Influences (Patient Influence; Clinical Autonomy; Consultant Experience; Perception of Disease Activity Score-28 (DAS28) Outcome).

Conclusions

Factors that influenced anti-TNF prescribing decisions were multifaceted, seemed to vary by region, and may facilitate divergence from published clinical recommendations. Strategic behavior appeared to illustrate a conflict between uniform treatment recommendations and clinical autonomy. These influences may contribute to understanding sources of regional variation in clinical practice for rheumatoid arthritis.

Patient Perspectives on Intravenous Biologics for Rheumatologic Disease

OBJECTIVE

Two surveys were conducted with patients with rheumatologic diseases to evaluate perceptions of different routes of administration (intravenous [IV] or subcutaneous [SC]) for biologic therapy.

METHODS

In Survey I, patient preferences toward biologic treatment were evaluated at a rheumatology practice in Buffalo, New York. In Survey II, Canadian patients enrolled in the BioAdvance patient support program and scheduled to receive IV biologic therapy were asked about their opinions of IV treatment.

RESULTS

In Survey I, 243 rheumatology patients participated. Median patient age was 60 years, 76% were female, and 44% were naive to treatment with biologic agents. Among biologic-naive patients, the majority (56%) were open to either SC or IV treatment; biologic-naive women were more likely than men to express a preference for the route of administration. In Survey II, 1,598 patients from the BioAdvance program (including 306 rheumatology patients) completed the full survey. Among the rheumatology patients, the median age was 49 years, 58% were female, and 61% had not previously taken biologics before enrolling in the BioAdvance program. The median rating of IV favorability (on a 10-point scale, with higher numbers indicating increased favorability) recalled by rheumatology patients was 5 prior to their first program infusion, which increased to 9 after multiple treatment infusions.

CONCLUSION

These survey results indicate that patients with rheumatoid arthritis are generally open to IV treatment and express high satisfaction with IV therapy. Additional patient and provider education may improve shared decision-making regarding biologic therapy administration options.

Switching of biological therapies in Brazilian patients with rheumatoid arthritis

Aim:

To assess drug switching, rates of remission and disease activity in Brazilian patients with rheumatoid arthritis (RA) treated with biologic agents.

Materials & methods:

Using a retrospective method, a total of 94 adult patients were included.

Results:

Anti-TNF was the first choice therapy in 85 (90.4%) patients. After an average of 8 years of follow-up, 55 (59%) patients were taking anti-TNF, 18 (19%) abatacept, eight (9%) tocilizumab and 13 (14%) rituximab. In this period, 99 switches of biological therapy were registered in 55 patients.

Conclusion:

After 8 years of follow-up, 54% of the RA patients on biological therapy were still experiencing high or moderate activity despite established treatment, including switching between different biologic agents.

Biological therapies are new drugs made through biotechnology processes that have greatly improved the treatment of RA. However, sometimes biologic agents must be switched to another biologic or other therapy due to lack of response, intolerance, adverse effects or other reasons. This study aimed to assess drug switching, rates of remission and disease activity in Brazilian patients with RA treated with biologics. Within a follow-up of 8 years, 99 switches of biological therapy were registered in 55 patients. After 8 years of follow-up, activity of disease still remained high or moderate in nearly half of patients.

Impact of Infliximab and Etanercept Biosimilars on Biological Disease-Modifying Antirheumatic Drugs Utilisation and NHS Budget in the UK

OBJECTIVE

Biological disease-modifying antirheumatic drugs (bDMARDs) are effective but expensive options for treating rheumatoid arthritis. The introduction of infliximab and etanercept biosimilars presents a significant potential cost saving in a financially constrained health system such as the National Health Service (NHS) in the UK. This study examines the impact of the introduction of infliximab and etanercept biosimilars on the utilisation of bDMARDs and subsequent budget impact.

METHODS

We conducted an interrupted time series analysis of secondary care utilisation data in rheumatology specialities from the DEFINE database, between March 2014 and February 2017.

RESULTS

The cumulative cost savings from the introduction of infliximab and etanercept biosimilars was £38.8 million over 2 years. There was a statistically significant increase in average monthly utilisation of bDMARDs for adalimumab (0.48%), certolizumab pegol (1.90%), golimumab (3.06%), abatacept (2.97%) and tocilizumab (2.24%), but not for etanercept. In contrast, the overall utilisation of infliximab decreased slightly by an average of 0.03% per month. The introduction of infliximab biosimilars negatively affected the monthly utilisation of branded infliximab significantly. Similarly, the introduction of an etanercept biosimilar negatively affected the monthly utilisation of branded etanercept significantly.

CONCLUSIONS

The introduction of bDMARDs biosimilars has resulted in considerable cost savings to the NHS, with the branded products reducing their prices in response to the availability of less expensive biosimilars and competition between the biosimilars themselves. Our results also suggest that when a biosimilar is available for a directly comparable branded molecule, price is the key influencing factor in the prescribing of a specific product.

Long-term follow-up of secondary amyloidosis patients treated with tumor necrosis factor inhibitor therapy: A STROBE-compliant observational study

There are no treatment modalities, which were proven to prevent the deposition of amyloid, proteinuria, and loss of renal function due to amyloidosis. Anti-tumor necrosis factor agents (anti-TNFs) were shown to decrease the production of serum amyloid A protein.We aimed to evaluate the long-term efficacy and safety of anti-TNFs in secondary (AA) amyloidosis patients treated in a single center.Thirty-seven patients with AA amyloidosis were started an anti-TNF for AA amyloidosis between March 2001 and June 2008 and followed until May 2016 unless deceased. They were surveyed for the endpoints of death, development of end-stage renal disease (ESRD), switch to another agent due to worsening of amyloidosis and adverse events.Among the 37 patients, 12 (32%) had died, 9 (24%) had ESRD, and 8 (22%) had started another group of biologic due to worsening of amyloidosis indicated by an increase in proteinuria, 5 (14%) patients are still doing well with anti-TNFs, and 3 (8%) are off treatment at the end of a median follow-up of 10 (interquartile range [IQR]: 5.5-10.5) years since the start of anti-TNFs and 10 (IQR: 8-13) years since the diagnosis of AA amyloidosis. Most common serious adverse events were sepsis and thrombotic events observed in 8 and 4 patients, respectively.Treatment with anti-TNFs may be associated with a higher survival rate compared with historic cohorts of AA amyloidosis, especially when started early with a lower serum creatinine level at baseline. Caution is needed regarding serious adverse events, especially infections.

Treatment patterns of rheumatoid arthritis in Japanese hospitals and predictors of the initiation of biologic agents

OBJECTIVE

To describe the usage of different biologic agents for rheumatoid arthritis (RA) in Japan over time and to identify factors that affects the decision to initiate treatment with biologic agents. Determinants of a switch to another biologic agent for patients who are already on biologic treatment were also analyzed.

RESEARCH DESIGN AND METHODS

We utilized a hospital claims database containing 36,504 Japanese patients with a confirmed RA diagnosis. To analyze the determinants of treatment choices, we applied logistic regression analysis taking into account socio-demographic and medical factors.

RESULTS

Analyses determined that 11.8% of diagnoses and 25.4% of treated patients in Japan receive a biologic agent. Significant factors associated with biologic treatment initiation include younger age, female sex, and a higher comorbidity index. The route of administration plays a major role when it comes to a switch between different biologic agents.

CONCLUSIONS

The lower likelihood of elderly patients to be initiated on biologic treatment might be explained by the risk aversion of Japanese physicians' and patients who are afraid of the potential side effects of biologics. This finding is also consistent with the notion of an age bias that impedes elderly patients from optimal access to biologic treatment. Because claims data does not contain clinical parameters such as disease activity the results should be validated in a clinical context.