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Luedders BA, Wheeler AM, Ascherman DP, Baker JF, Duryee MJ, Yang Y, Roul P, Wysham KD, Monach P, Reimold A, Kerr GS, Kunkel G, Cannon GW, Poole JA, Thiele GM, Mikuls TR, England BR. Plasma Matrix Metalloproteinase Concentrations and Risk of Interstitial Lung Disease in a Prospective Rheumatoid Arthritis Cohort. Arthritis Rheumatol 2024. [PMID: 38268499 DOI: 10.1002/art.42812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/20/2023] [Accepted: 01/23/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVE To evaluate the associations of plasma matrix metalloproteinases (MMPs) with prevalent and incident interstitial lung disease (ILD) in people with rheumatoid arthritis (RA). METHODS Within a multicenter, prospective cohort of US veterans with RA, we performed a cross-sectional study of prevalent ILD and cohort study of incident ILD. ILD diagnoses were validated by medical record review of provider diagnoses and chest imaging and/or pathology reports. MMP-1, 3, 7, and 9 concentrations were measured in plasma samples, then standardized and categorized into quartiles. The associations of MMPs with prevalent and incident ILD were assessed with logistic (prevalent) and Cox (incident) regression models adjusted for RA-ILD risk factors. RESULTS Among 2,312 participants (88.9% male; mean age 63.8 years), 96 had prevalent ILD. Incident ILD developed in 130 participants over 17,378 person-years of follow-up (crude incidence rate 7.5/1,000 person-years). Participants with the highest quartile of MMP-7 concentrations had a nearly four-fold increased odds of prevalent ILD (adjusted odds ratio 3.78 [95% confidence interval (95% CI) 1.86-7.65]) and over two-fold increased risk of incident ILD (adjusted hazard ratio 2.33 [95% CI 1.35-4.02]). Higher MMP-9 concentrations were also associated with prevalent and incident ILD, as well as negatively correlated with forced vital capacity among those with prevalent ILD (r = -0.30, P = 0.005). CONCLUSION MMP-7 and MMP-9 were strongly associated with both prevalent and incident ILD in this large, multicenter RA cohort after adjustment for other RA-ILD risk factors. These population-level findings further support a potential pathogenic role for MMPs in RA-ILD and suggest that their measurement could facilitate RA-ILD risk stratification.
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Affiliation(s)
- Brent A Luedders
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | - Austin M Wheeler
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | - Dana P Ascherman
- Pittsburgh VA and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joshua F Baker
- Corporal Michael J. Crescenz VA Medical Center and University of Pennsylvania, Philadelphia
| | - Michael J Duryee
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | - Yangyuna Yang
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | - Punyasha Roul
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | | | | | | | - Gail S Kerr
- Washington, DC VA, Howard University, and Georgetown University, Washington, DC
| | - Gary Kunkel
- VA Salt Lake City Health Care System and University of Utah, Salt Lake City
| | - Grant W Cannon
- VA Salt Lake City Health Care System and University of Utah, Salt Lake City
| | | | - Geoffrey M Thiele
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | - Ted R Mikuls
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | - Bryant R England
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
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Santoleri F, Lasala R, Abrate P, Pestrin L, Pasut E, Modesti G, Musicco F, Fulgenzio C, Zuzolo E, Pieri G, Roperti M, Gazzola P, Gambera M, Martignoni I, Montresor V, De Vita F, Guarino F, Grossi L, Di Fabio L, Roberti C, Spoltore C, Tinari G, De Rosa S, Giannini R, Langella R, Mingolla G, Piccoli M, Costantini A. ADA_ETA_BIO2021: real-world evaluation of adherence, persistence, and cost-effectiveness of originator and biosimilar biologic drugs in the treatment of rheumatoid arthritis: a multicenter study in Italy. Curr Med Res Opin 2023; 39:1729-1735. [PMID: 37994874 DOI: 10.1080/03007995.2023.2287600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 11/21/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVES The objective was to assess the adherence, persistence, and costs of bDMARDs through a multicentre study of nine Italian hospital pharmacies. METHODS The drugs analysed were Abatacept, Adalimumab, Certolizumab, Etanercept, Golimumab and Tocilizumab.Adult subjects with Rheumatoid Arthritis were considered in the analysis.In this study, we calculated the following metrics: Adherence to treatment was evaluated as dose-intensity, which is the ratio between the amount of medication received and probably taken by the patient at home (Received Daily Dose, RDD) and the amount prescribed by the clinician (Prescribed Daily Dose, PDD). Persistence was calculated as the number of days between the first and last dispensing of the same drug. Lastly, costs were assessed based on persistence to treatment and normalized for adherence. RESULTS Adherence to treatment was found to be above 0.8 for all drugs studied. The median persistence for a 5-year treatment period was 1.4 years for Abatacept, 1.7 years for Adalimumab, 1.8 years for Certolizumab, 1.4 years for Etanercept, 1.3 years for Golimumab, and 1.6 years for Tocilizumab. CONCLUSIONS This multicentre retrospective observational study of bDMARDs used in the treatment of RA showed that, for all the drugs studied, there was no problem with adherence to treatment but rather a difficulty in maintaining treatment with the same drug over time.
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Affiliation(s)
| | - Ruggero Lasala
- Hospital Pharmacy of Corato, Local Health Unit of Bari, Bari, Italy
| | | | | | - Enrico Pasut
- Service of Pharmacy, Azienda Sanitaria Universitaria del Friuli Centrale (ASUFC), Udine, Italy
| | - Germana Modesti
- Service of Pharmacy, Azienda Sanitaria Universitaria del Friuli Centrale (ASUFC), Udine, Italy
| | - Felice Musicco
- San Gallicano Dermatological Institute - IRCCS, Rome Italy
| | | | - Eva Zuzolo
- San Gallicano Dermatological Institute - IRCCS, Rome Italy
| | | | | | - Pietro Gazzola
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marco Gambera
- "Ospedale P. Pederzoli" Casa di Cura Privata S.p.A.Via Monte Baldo
| | | | | | | | | | - Laura Grossi
- Chieti General Hospital, Via dei Vestini, Chieti Italy
| | | | | | | | | | | | | | - Roberto Langella
- Pharmacy Department, Agency for Health Protection (ATS) of Milan,Italy
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Sparks JA, Harrold LR, Simon TA, Wittstock K, Kelly S, Lozenski K, Khaychuk V, Michaud K. Comparative effectiveness of treatments for rheumatoid arthritis in clinical practice: A systematic review. Semin Arthritis Rheum 2023; 62:152249. [PMID: 37573754 DOI: 10.1016/j.semarthrit.2023.152249] [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: 12/09/2022] [Revised: 07/11/2023] [Accepted: 07/24/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE To assess real-world comparative effectiveness studies of biologic (b) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARDs) in adults with rheumatoid arthritis (RA) through a systematic review. METHODS We searched Medline for journal articles (2001-2021) and Embase® for abstracts presented at the European Alliance of Associations for Rheumatology and American College of Rheumatology (ACR) 2020 and 2021 annual meetings on non-randomized studies comparing the effectiveness of b/tsDMARDs using ACR-recommended disease activity measures, measures of functional status, and patient-reported outcomes (HAQ, PROMIS PF, patient pain, Patient and Physician Global Assessment of disease activity). Methodological heterogeneity between studies precluded meta-analyses. Risk of bias was assessed using the Cochrane Risk Of Bias In Non-randomized Studies of Interventions-I tool. RESULTS Of 1283 records screened, 68 were selected for data extraction, of which 1 was excluded due to critical risk of bias. Most studies were multicenter observational cohort/registry studies (n = 60) and were published between 2011 and 2021 (n = 60). Mean or median reported RA duration was between 6 and 15 years. Disease Activity Score in 28 joints (46 studies), Clinical Disease Activity Index (37 studies), and Health Assessment Questionnaire-Disability Index (32 studies) were the most common outcomes used in clinical practice, with regional differences identified. The most common comparison was between tumor necrosis factor inhibitors (TNFis) and non-TNFi bDMARDs (35 studies). There were no evident differences between b/tsDMARDs in clinical effectiveness. CONCLUSION This systematic review summarizing real-world evidence from a very large number of global studies found there are many effective options for the treatment of RA, but relatively less evidence to support the use of any one b/tsDMARD or drug class over another. Treatment for patients with RA should be tailored to suit individual clinical profiles. Further research is needed to identify whether specific patient subgroups may benefit from specific drug classes.
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Affiliation(s)
- Jeffrey A Sparks
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Leslie R Harrold
- CorEvitas, LLC, Waltham, MA, USA; University of Massachusetts Medical School, Worcester, MA, USA
| | | | | | | | | | | | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, NE, USA; FORWARD, The National Databank for Rheumatic Diseases, Wichita, KS, USA.
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Wallace BI, England BR, Baker JF, Rojas J, Sauer BC, Roul P, Kunkel GA, Braaten TJ, Petro A, Mikuls TR, Cannon GW. Lowering Expectations: Glucocorticoid Tapering Among Veterans With Rheumatoid Arthritis Achieving Low Disease Activity on Stable Biologic Therapy. ACR Open Rheumatol 2023; 5:437-442. [PMID: 37491906 PMCID: PMC10502811 DOI: 10.1002/acr2.11584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/17/2023] [Indexed: 07/27/2023] Open
Abstract
OBJECTIVE In the Steroid EliMination In Rheumatoid Arthritis (SEMIRA) trial, 65% of patients with rheumatoid arthritis (RA) in low disease activity (LDA) on stable biologic therapy successfully tapered glucocorticoids. We aimed to evaluate real-world rates of glucocorticoid tapering among similar patients in the Veterans Affairs Rheumatoid Arthritis registry. METHODS Within a multicenter, prospective RA cohort, we used registry data and linked pharmacy claims from 2003 to 2021 to identify chronic prednisone users achieving LDA after initiating a new biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD). We defined the index date as first LDA occurring 60 to 180 days after b/tsDMARD initiation. The primary outcome of successful tapering, assessed at day 180 after LDA, required a 30-day averaged prednisone dose both less than or equal to 5mg/day and at least 50% lower than at the index date. The secondary outcome was discontinuation, defined as a prednisone dose of 0 mg/day at days 180 through 210. We used univariate statistics to compare patient characteristics by fulfillment of the primary outcome. RESULTS We evaluated 100 b/tsDMARD courses among 95 patients. Fifty-four courses resulted in successful tapering; 33 resulted in discontinuation. Positive rheumatoid factor, higher erythrocyte sedimentation rate, more background DMARDs, shorter time from b/tsDMARD initiation to LDA, and higher glucocorticoid dose 30 days before LDA were associated with greater likelihood of successful tapering. CONCLUSION In a real-world RA cohort of chronic glucocorticoid users in LDA, half successfully tapered and a third discontinued prednisone within 6 months of initiating a new b/tsDMARD. Claims-based algorithms of glucocorticoid tapering and discontinuation may be useful to evaluate predictors of tapering in administrative data sets.
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Affiliation(s)
- Beth I. Wallace
- Center for Clinical Management ResearchVA Ann Arbor Healthcare System and University of MichiganAnn Arbor
| | - Bryant R. England
- University of Nebraska Medical Center and Veterans Affairs Nebraska‐Western Iowa Health Care SystemOmaha
| | - Joshua F. Baker
- Hospital of the University of Pennsylvania and Philadelphia VA Medical CenterPhiladelphia
| | - Jorge Rojas
- VA Salt Lake City Healthcare System, Salt Lake City, Utah, and VA Puget Sound Healthcare SystemSeattleWashington
| | | | | | - Gary A. Kunkel
- VA Salt Lake City Healthcare System and University of UtahSalt Lake City
| | - Tawnie J. Braaten
- VA Salt Lake City Healthcare System and University of UtahSalt Lake City
| | | | - Ted R. Mikuls
- University of Nebraska Medical Center and Veterans Affairs Nebraska‐Western Iowa Health Care SystemOmaha
| | - Grant W. Cannon
- VA Salt Lake City Healthcare System, Salt Lake City, Utah, and VA Puget Sound Healthcare SystemSeattleWashington
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5
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Sullivan E, Kershaw J, Blackburn S, Choi J, Curtis JR, Boklage S. Biologic Disease-Modifying Antirheumatic Drug Prescription Patterns for Rheumatoid Arthritis Among United States Physicians. Rheumatol Ther 2020; 7:383-400. [PMID: 32318979 PMCID: PMC7211222 DOI: 10.1007/s40744-020-00203-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Some patients with rheumatoid arthritis (RA) using tumor necrosis factor inhibitors (TNFi) experience inefficacy or lack of tolerability and hence switch to another TNFi (cycling) or to a therapy with another mode of action (switching). This study examined patient characteristics, prescribing patterns and treatment practice for RA in the United States. METHODS Data were from the Adelphi Disease Specific Programme (Q2-Q3 2016). Rheumatologists completed a survey and patient record forms for adult patients with RA who had received ≥ 1 targeted therapy. Patients were grouped by class of first-used targeted therapy, and monotherapy vs. combination therapy. TNFi patients who received ≥ 1 targeted therapy were classified as cyclers or switchers. Univariate analyses compared patient characteristics and physician factors across the analysis groups. RESULTS Overall, 631 patients received ≥ 1 targeted therapy; 535 were prescribed a TNFi as first targeted therapy, 53 a nonTNFi biologic disease-modifying antirheumatic drug (bDMARD), and 43 tofacitinib. Of 577 patients with known conventional synthetic (cs) DMARD status, 18.7% were prescribed monotherapy and 81.3% combination therapy. Combination therapy patients received significantly more concomitant medications prior to initiation of first targeted therapy than monotherapy patients (P < 0.05). The top reason for physicians to prescribe first use targeted therapy was strong overall efficacy (79.9%). Of 163 patients who progressed to second targeted therapy, 60.7% were cyclers. A lower proportion of cyclers persisted on their first use targeted therapy versus switchers (P = 0.03). The main reason physicians gave for switching patients at this stage was worsening condition (46.6%). CONCLUSIONS Most patients were prescribed a TNFi as their first targeted therapy; over half then cycled to another TNFi. This suggests other factors may influence second use targeted treatment choice and highlights the need for greater understanding of outcomes associated with subsequent treatment choices and potential benefits of switching.
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Affiliation(s)
| | | | | | | | | | - Susan Boklage
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA.
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Initiation of Disease-Modifying Therapies in Rheumatoid Arthritis Is Associated With Changes in Blood Pressure. J Clin Rheumatol 2019; 24:203-209. [PMID: 29664818 DOI: 10.1097/rhu.0000000000000736] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE This study reports the effect of disease-modifying therapies for rheumatoid arthritis (RA) on systolic and diastolic blood pressure (SBP, DBP) over 6 months and incident hypertension over 3 years in a large administrative database. METHODS We used administrative Veterans Affairs databases to define unique dispensing episodes of methotrexate, leflunomide, sulfasalazine, hydroxychloroquine, tumor necrosis factor inhibitors, and prednisone among patients with RA. Changes in SBP and DBP in the 6 months before disease-modifying antirheumatic drug initiation were compared with changes observed in the 6 months after initiation. The risk of incident hypertension within 3 years (new diagnosis code for hypertension and prescription for antihypertensive) was also assessed. Multivariable models and propensity analyses assessed the impact of confounding by indication. RESULTS A total of 37,900 treatment courses in 21,216 unique patients contributed data. Overall, there were no changes in SBP or DBP in 6 months prior to disease-modifying antirheumatic drug initiation (all P > 0.62). In contrast, there was a decline in SBP (β = -1.08 [-1.32 to -0.85]; P < 0.0001) and DBP (β = -0.48 [-0.62 to -0.33]; P < 0.0001) over the 6 months following initiation. The greatest decline was observed among methotrexate and hydroxychloroquine users. Methotrexate users were 9% more likely to have optimal blood pressure (BP) after 6 months of treatment. Patients treated with leflunomide had increases in BP and a greater risk of incident hypertension compared with patients treated with methotrexate (hazard ratio, 1.53 [1.21-1.91]; P < 0.001). CONCLUSIONS Blood pressure may improve with treatment of RA, particularly with methotrexate or hydroxychloroquine. Leflunomide use, in contrast, is associated with increases in BP and a greater risk of incident hypertension.
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Cannon GW, Erickson AR, Teng CC, Huynh T, Austin S, Wade SW, Stolshek BS, Collier DH, Mutebi A, Sauer BC. Tumour necrosis factor inhibitor exposure and radiographic outcomes in Veterans with rheumatoid arthritis: a longitudinal cohort study. Rheumatol Adv Pract 2019; 3:rkz015. [PMID: 31763619 DOI: 10.1093/rap/rkz015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 03/31/2019] [Indexed: 01/23/2023] Open
Abstract
Objectives The aim was to estimate the impact of TNF inhibitor (TNFi) exposure on radiographic disease progression in US Veterans with RA during the first year after initiating therapy. Methods This historical longitudinal cohort design used clinical and claims data to evaluate radiographic progression after initiation of TNFi. US Veterans with RA initiating TNFi treatment (index date), ≥ 6 months pre-index and ≥ 12 months post-index VA enrolment/activity, and initial (6 months pre-index to 30 days post-index) and follow-up (10-18 months post-index) bilateral hand radiographs were eligible. The cumulative TNFi exposure and change in modified Sharp score (MSS) between initial and follow-up radiographs were calculated. The percentage of patients with clinically meaningful change in MSS (≥ 5) for each month of exposure was assessed using a longitudinal marginal structural model with inverse probability of treatment weights. Mean values and CIs were generated using 1000 bootstrapped samples. Results For 246 eligible patients, the mean (s.d.) age was 58 (11) years; 81% were male. The mean (s.d.) initial MSS was 19.6 (33.4) (range 0-214). The mean change (s.d.) in MSS was 0.3 (3.6) (median 0, range -19 to 22). Patients with the greatest exposure had the least radiographic progression for both crude and adjusted model analyses. Adjusted rates of MSS change ≥ 5 points (95% CI) were 10.6% (9.8%, 11.4%) for patients with 3 months of exposure compared with 5.4% (5.1%, 5.7%) for patients with 12 months of exposure. Conclusion One-year changes in radiographic progression were small. Patients with the greatest cumulative TNFi exposure experienced the least progression.
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Affiliation(s)
- Grant W Cannon
- Salt Lake City VA Medical Center, University of Utah, Salt Lake City, UT, USA.,Division of Rheumatology, University of Utah, Salt Lake City, UT, USA
| | - Alan R Erickson
- VA Nebraska-Western Iowa Health Care System and Division of Rheumatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Chia-Chen Teng
- Salt Lake City VA Medical Center, University of Utah, Salt Lake City, UT, USA.,Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Tina Huynh
- Salt Lake City VA Medical Center, University of Utah, Salt Lake City, UT, USA.,Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Sharon Austin
- Salt Lake City VA Medical Center, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Sally W Wade
- Wade Outcomes Research and Consulting, Salt Lake City, UT, USA
| | | | | | | | - Brian C Sauer
- Salt Lake City VA Medical Center, University of Utah, Salt Lake City, UT, USA.,Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
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Cohen SB, Kremer JM, Dandreo KJ, Reed GW, Magner R, Shan Y, Kafka S, DeHoratius RJ, Ellis L, Parenti D. Outcomes of infliximab dose escalation in patients with rheumatoid arthritis. Clin Rheumatol 2019; 38:2501-2508. [PMID: 31049762 DOI: 10.1007/s10067-019-04543-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 03/26/2019] [Accepted: 04/01/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Dose escalation of infliximab in both primary and secondary nonresponders is widely reported; however, the usefulness of dose escalation has been disputed. The objective of this analysis is to evaluate trends in clinical efficacy following multiple infliximab dose escalations in patients with rheumatoid arthritis (RA). METHODS Patients enrolled in a US RA registry were included if they initiated infliximab at 3 mg/kg every 8 weeks, received ≥ 1 infliximab dose escalation within 12 months of initiation, and had ≥ 1 visit following dose escalation. Trends in mean Clinical Disease Activity Index (CDAI) and Health Assessment Questionnaire (HAQ) scores from visits following dose escalations were evaluated. RESULTS In patients who received 2 or 3 dose escalations, the initial (1 or 2) dose escalations resulted in reduced mean CDAI scores, but subsequent escalations did not further reduce disease activity. In patients who received ≥ 4 dose escalations, mean CDAI scores did not further reduce disease activity over time. Mean HAQ scores were stable over time in patients who received 2 or 3 dose escalations. In patients who received ≥ 4 dose escalations, mean HAQ scores decreased following 1 dose escalation but progressively increased following subsequent dose escalations. CONCLUSION Initial dose escalations (from 3 mg/kg to the equivalent of approximately 5 to 7 mg/kg) may be useful in controlling disease activity; however, there may be diminishing clinical benefit of further escalations, which can also increase the potential risk for infection and increase incremental drug costs. KEY POINTS • Initial infliximab dose escalations (1 to 2) may be useful in lowering disease activity in patients with rheumatoid arthritis. • There does not appear to be a clinical benefit in infliximab dose escalations above the equivalent of 5 to 7 mg/kg.
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Affiliation(s)
- Stanley B Cohen
- Metroplex Clinical Research Center, 8144 Walnut Hill Lane, Suite 800, Dallas, TX, 75231, USA.
| | - Joel M Kremer
- The Center for Rheumatology, Albany Medical College, 4 Tower Place, 8th Floor, Albany, NY, 12203, USA.,Corrona, LLC, 1440 Main Street, Suite 310, Waltham, MA, 02451, USA
| | | | - George W Reed
- Corrona, LLC, 1440 Main Street, Suite 310, Waltham, MA, 02451, USA
| | - Robert Magner
- University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA, 01655, USA
| | - Ying Shan
- Corrona, LLC, 1440 Main Street, Suite 310, Waltham, MA, 02451, USA
| | - Shelly Kafka
- Janssen Scientific Affairs, LLC, 800 Ridgeview Drive, Horsham, PA, 19044, USA
| | - Raphael J DeHoratius
- Janssen Scientific Affairs, LLC, 800 Ridgeview Drive, Horsham, PA, 19044, USA.,Sidney Kimmel School of Medicine, Thomas Jefferson University, 1025 Walnut Street #100, Philadelphia, PA, 19107, USA
| | - Lorie Ellis
- Janssen Scientific Affairs, LLC, 800 Ridgeview Drive, Horsham, PA, 19044, USA
| | - Dennis Parenti
- Janssen Scientific Affairs, LLC, 800 Ridgeview Drive, Horsham, PA, 19044, USA
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Wood PR, Manning E, Baker JF, England B, Davis L, Cannon GW, Mikuls TR, Caplan L. Blood glucose changes surrounding initiation of tumor-necrosis factor inhibitors and conventional disease-modifying anti-rheumatic drugs in veterans with rheumatoid arthritis. World J Diabetes 2018; 9:53-58. [PMID: 29531640 PMCID: PMC5840570 DOI: 10.4239/wjd.v9.i2.53] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/15/2018] [Accepted: 03/07/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To determine the scope of acute hypoglycemic effects for certain anti-rheumatic medications in a large retrospective observational study.
METHODS Patients enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry were selected who, during follow-up, initiated treatment with tumor necrosis factor inhibitors (TNFi’s, including etanercept, adalimumab, infliximab, golimumab, or certolizumab), prednisone, or conventional disease-modifying anti-rheumatic drugs (DMARDs), and for whom proximate random blood glucose (RBG) measurements were available within a window 2-wk prior to, and 6 mo following, medication initiation. Similar data were obtained for patients with proximate values available for glycosylated hemoglobin A1C values within a window 2 mo preceding, and 12 mo following, medication initiation. RBG and A1C measurements were compared before and after initiation events using paired t-tests, and multivariate regression analysis was performed including established comorbidities and demographics.
RESULTS Two thousands one hundred and eleven patients contributed at least one proximate measurement surrounding the initiation of any examined medication. A significant decrease in RBG was noted surrounding 653 individual hydroxychloroquine-initiation events (-3.68 mg/dL, P = 0.04), while an increase was noted for RBG surrounding 665 prednisone-initiation events (+5.85 mg/dL, P < 0.01). A statistically significant decrease in A1C was noted for sulfasalazine initiation, as measured by 49 individual initiation events (-0.70%, P < 0.01). Multivariate regression analyses, using methotrexate as the referent, suggest sulfasalazine (β = -0.58, P = 0.01) and hydroxychloroquine (β = -5.78, P = 0.01) use as predictors of lower post-medication-initiation RBG and A1C values, respectively. Analysis by drug class suggested prednisone (or glucocorticoids) as predictive of higher medication-initiation event RBG among all start events as compared to DMARDs, while this analysis did not show any drug class-level effect for TNFi. A diagnosis of congestive heart failure (β = 4.69, P = 0.03) was predictive for higher post-initiation RBG values among all medication-initiation events.
CONCLUSION No statistically significant hypoglycemic effects surrounding TNFi initiation were observed in this large cohort. Sulfasalazine and hydroxychloroquine may have epidemiologically significant acute hypoglycemic effects.
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Affiliation(s)
- Patrick R Wood
- Denver Veterans Affairs Medical Center, Division of Rheumatology, University of Colorado, Aurora, CO 80045, United States
| | - Evan Manning
- Denver Veterans Affairs Medical Center, Division of Rheumatology, University of Colorado, Aurora, CO 80045, United States
| | - Joshua F Baker
- Philadelphia Veterans Affairs Medical Center, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Bryant England
- Omaha Veterans Affairs Medical Center, Division of Rheumatology, University of Nebraska, Omaha, NE 68198, United States
| | - Lisa Davis
- Denver Health and Hospital, Division of Rheumatology, University of Colorado, Aurora, CO 80045, United States
| | - Grant W Cannon
- George Wahlen Veterans Affairs Medical Center, Division of Rheumatology, University of Utah, Salt Lake City, UT 84148, United States
| | - Ted R Mikuls
- Omaha Veterans Affairs Medical Center, Division of Rheumatology, University of Nebraska, Omaha, NE 68198, United States
| | - Liron Caplan
- Denver Veterans Affairs Medical Center, Division of Rheumatology, University of Colorado, Aurora, CO 80045, United States
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Murage MJ, Tongbram V, Feldman SR, Malatestinic WN, Larmore CJ, Muram TM, Burge RT, Bay C, Johnson N, Clifford S, Araujo AB. Medication adherence and persistence in patients with rheumatoid arthritis, psoriasis, and psoriatic arthritis: a systematic literature review. Patient Prefer Adherence 2018; 12:1483-1503. [PMID: 30174415 PMCID: PMC6110273 DOI: 10.2147/ppa.s167508] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Proper adherence and persistence to medications are crucial for better quality of life and improved outcomes in rheumatoid arthritis (RA), psoriasis (PsO), and psoriatic arthritis (PsA). We systematically describe current adherence and persistence patterns for RA, PsO, and PsA, with a focus on biologics and identifying factors associated with adherence and persistence. PATIENTS AND METHODS Using various databases, a systematic literature review of US-based studies published from 2000 to 2015 on medication adherence and persistence to biologics and associated factors was conducted among patients with RA, PsO, and PsA. RESULTS Using the medication possession ratio or the percentage of days covered >80%, RA and PsO adherence rates for etanercept, adalimumab, and infliximab ranged from 16% to 73%, 21% to 70%, and 38% to 81%, respectively. Using the criteria of a ≥45-day gap, RA persistence rates for etanercept, adalimumab, and infliximab ranged from 46% to 89%, 42% to 94%, and 41% to 76%, respectively. In PsO, persistence rates for etanercept and adalimumab ranged from 34% to 50% and 50% to 62%, respectively. Similar persistence rates were observed in PsA. Experienced biologics users showed better adherence and persistence. Younger age, female gender, higher out-of-pocket costs, greater disease severity, and more comorbidities were associated with lower adherence and persistence rates. Qualitative surveys revealed that nonpersistence was partly due to perceived ineffectiveness and safety/tolerability concerns. CONCLUSION Biologic adherence and persistence rates in RA, PsO, and PsA in the United States were low, with significant opportunity for improvement. Various factors - including decrease in disease severity; reduction of comorbidities; lower out-of-pocket costs; refilling at specialty pharmacies; and awareness of drug effectiveness, safety, and tolerability - can inform targeted approaches to improve these rates.
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Affiliation(s)
| | | | - Steven R Feldman
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | | | - Russel T Burge
- Eli Lilly and Company, Indianapolis, IN, USA,
- University of Cincinnati, Division of Pharmaceutical Sciences, Winkle College of Pharmacy, Cincinnati, OH, USA
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Rheumatoid arthritis patients treated in trial and real world settings: comparison of randomized trials with registries. Rheumatology (Oxford) 2017; 57:354-369. [DOI: 10.1093/rheumatology/kex394] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Indexed: 12/18/2022] Open
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Thorne C, Boire G, Chow A, Garces K, Liu F, Poulin-Costello M, Walker V, Haraoui B. Dose Escalation and Co-therapy Intensification Between Etanercept, Adalimumab, and Infliximab: The CADURA Study. Open Rheumatol J 2017; 11:123-135. [PMID: 29296125 PMCID: PMC5744265 DOI: 10.2174/1874312901711010123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 09/05/2017] [Accepted: 09/26/2017] [Indexed: 01/04/2023] Open
Abstract
Objective To compare anti-TNF dose escalation, DMARD and/or glucocorticoid intensification, switches to another biologic, and drug and drug-related costs over 12 and 18 months for rheumatoid arthritis (RA) patients initiating etanercept (ETN), adalimumab (ADA), or infliximab (IFX) in routine clinical practice across Canada. Methods A retrospective chart review of biologic-naïve adult RA patients newly initiating ADA, ETN, or IFX between January 01, 2006 and December 31, 2012 from 11 practices across Canada. Results There were 314 patients in the 12-month analysis and 217 in the 18-month analysis. No dose escalation occurred with ETN over 12 and 18 months versus 38% and 32% for IFX (p<0.001) and 2% and 2% for ADA (p=0.199, p=0.218). Over 18 months, dose escalation and/or DMARD and/or glucocorticoid intensification was less frequent among ETN (16%) versus IFX (44%, p=0.005) and ADA (34%, p=0.004). By 18 months, 22% of patients initiating ADA had switched to another biologic compared with 6% of ETN patients (p=0.001).Patients initiating ETN had lower total (drug and drug-related) costs over 12 and 18 months compared to IFX, and no difference compared to ADA when adjusted for potential confounders. Patients with dose escalation had higher costs compared to those with no dose escalation. Conclusion Physicians were more likely to escalate the dose of IFX, but optimize co-therapy with ADA and ETN. ETN patients had no dose escalation and were less likely to have DMARD and/or glucocorticoid intensification than ADA patients. ETN-treated patients had lower costs compared to IFX patients.
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Affiliation(s)
- Carter Thorne
- The Arthritis Program Research Group, Southlake Regional Health Centre, c/o 43 Lundy's Lane, Newmarket, ON, L3Y 3R7, Canada
| | - Gilles Boire
- Centre Hospitalier Universitaire de Sherbrooke (CIUSSS de l'Estrie-CHUS), Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Andrew Chow
- Credit Valley Rheumatology, Mississauga, ON, Canada
| | | | - Fang Liu
- Optum, 5500 North Service Road, Suite 501, Burlington, ON, L7L 6W6, Canada
| | | | - Valery Walker
- Optum, 5500 North Service Road, Suite 501, Burlington, ON, L7L 6W6, Canada
| | - Boulos Haraoui
- Institut de Rhumatologie de Montreal, Montreal, QC, Canada
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Choy EH, Bernasconi C, Aassi M, Molina JF, Epis OM. Treatment of Rheumatoid Arthritis With Anti-Tumor Necrosis Factor or Tocilizumab Therapy as First Biologic Agent in a Global Comparative Observational Study. Arthritis Care Res (Hoboken) 2017. [PMID: 28622454 PMCID: PMC5656814 DOI: 10.1002/acr.23303] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective To compare clinical effectiveness between tocilizumab and tumor necrosis factor inhibitors (TNFi) in patients with rheumatoid arthritis (RA) and inadequate response to conventional synthetic disease‐modifying antirheumatic drugs initiating biologic therapy. Methods Patients prescribed tocilizumab (intravenous) or TNFi were prospectively observed in routine clinical practice for 52 weeks across 158 sites in 26 countries. The primary observation was the change from baseline in Disease Activity Score based on 28 joints using the erythrocyte sedimentation rate (DAS28‐ESR) at week 24 using analysis of covariance for between‐groups comparison. Secondary end points included Clinical Disease Activity Index (CDAI) and patient‐reported outcomes at weeks 24 and 52. Results Of 1,216 patients, 35% initiated tocilizumab and 65% initiated TNFi. RA duration was shorter, and disease activity and corticosteroid use were higher in tocilizumab patients. Tocilizumab‐treated patients had greater improvement in DAS28‐ESR at weeks 24 and 52 (week 24 difference [95% confidence interval] in adjusted means: −0.831 [−1.086, −0.576]; P < 0.001). Change from baseline in CDAI was also greater with tocilizumab (adjusted means difference: week 24, −3.48; week 52, −4.60; both P < 0.001). Tocilizumab‐treated patients had more improvement in the Health Assessment Questionnaire disability index than TNFi‐treated patients (P < 0.05). The cumulative probability of drug discontinuation at week 52 was lower with tocilizumab (15%) than TNFi (27%; P < 0.001, unadjusted analysis). Unadjusted frequencies (events per 100 patient‐years) for tocilizumab and TNFi were 6.44 and 11.99 for serious adverse events, 1.98 and 5.03 for serious infections, and 0.74 and 0.77 for deaths, respectively. Conclusion Patients initiating tocilizumab experienced greater effectiveness and drug survival than those initiating TNFi in an observational setting.
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Baker JF, Sauer BC, Cannon GW, Teng CC, Michaud K, Ibrahim S, Jorgenson E, Davis L, Caplan L, Cannella A, Mikuls TR. Changes in Body Mass Related to the Initiation of Disease-Modifying Therapies in Rheumatoid Arthritis. Arthritis Rheumatol 2017; 68:1818-27. [PMID: 26882094 DOI: 10.1002/art.39647] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 02/11/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Unintentional weight loss is important and can be predictive of long-term outcomes in patients with rheumatoid arthritis (RA). This study was undertaken to assess how primary therapies for RA may influence changes in body mass index (BMI) in RA patients from a large administrative database. METHODS Unique dispensing episodes of methotrexate, prednisone, leflunomide, and tumor necrosis factor inhibitors (TNFi) administered to RA patients were identified from the US Department of Veterans Affairs pharmacy databases. Values for C-reactive protein (CRP) level and BMI closest to the time point within 30 days of the treatment course start date and at follow-up time points were linked. Missing laboratory values were imputed. Weight loss was defined as a decrease in BMI of >1 kg/m(2) . Regression models were used to evaluate changes in BMI during each drug treatment as compared to treatment with methotrexate. To assess the impact of confounding by indication, propensity scores for use of each drug were incorporated in analyses using matched-weighting techniques. RESULTS In total, 52,662 treatment courses in 32,859 RA patients were identified. At 6 months from the date of prescription fill, weight gain was seen among patients taking methotrexate, those taking prednisone, and those taking TNFi. On average, compared to methotrexate-treated patients, prednisone-treated patients had significantly more weight gain, while leflunomide-treated patients demonstrated weight loss. In multivariable models, more weight loss (β = -0.41 kg/m(2) , 95% confidence interval [95% CI] -0.46, -0.36; P < 0.001) and a greater risk of weight loss (odds ratio 1.73, 95% CI 1.55, 1.79; P < 0.001) were evident among those receiving leflunomide compared to those receiving methotrexate. Treatment with prednisone was associated with greater weight gain (β = 0.072 kg/m(2) , 95% CI 0.042, 0.10; P < 0.001). These associations persisted in analyses adjusted for propensity scores and in sensitivity analyses. CONCLUSION Leflunomide is associated with significantly more, but modest, weight loss, while prednisone is associated with greater weight gain compared to other therapies for RA.
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Affiliation(s)
- Joshua F Baker
- Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia
| | - Brian C Sauer
- Salt Lake City VA Medical Center and University of Utah, Salt Lake City
| | - Grant W Cannon
- Salt Lake City VA Medical Center and University of Utah, Salt Lake City
| | - Chia-Chen Teng
- Salt Lake City VA Medical Center and University of Utah, Salt Lake City
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and National Data Bank for Rheumatic Diseases, Wichita, Kansas
| | - Said Ibrahim
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, and University of Pennsylvania, Philadelphia
| | - Erik Jorgenson
- Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia
| | - Lisa Davis
- Denver VA Medical Center, Denver, Colorado
| | | | - Amy Cannella
- University of Nebraska Medical Center, Omaha, VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
| | - Ted R Mikuls
- University of Nebraska Medical Center, Omaha, VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
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Schwab P, Sayles H, Bergman D, Cannon GW, Michaud K, Mikuls TR, Barton J. Utilization of Care Outside the Veterans Affairs Health Care System by US Veterans With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2017; 69:776-782. [PMID: 27696766 PMCID: PMC5376369 DOI: 10.1002/acr.23088] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 08/17/2016] [Accepted: 09/13/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Many veterans enrolled in Veterans Affairs (VA) health care systems also receive care through other health care systems. Both VA and non-VA health care use must therefore be considered when conducting research in this population. This study characterized dual-care utilization in veterans with rheumatoid arthritis (RA) and explored associations with RA disease activity. METHODS Through a questionnaire mailed to RA patients at 3 VA sites, veterans reported medical services by non-VA primary care and subspecialty providers, comorbidities, non-VA medications, and hospitalizations. Disease Activity Score in 28 joints (DAS28) and Multidimensional Health Assessment Questionnaire (MD-HAQ) scores were recorded during VA clinic visits, and respondent groups were compared. RESULTS Of the 510 participants surveyed, 318 (62%) responded. Respondents were older (ages 69 versus 66 years; P = 0.006), more likely nonsmokers (80% versus 67%; P = 0.001), and had lower disease activity (DAS28 3.3 versus 3.8; P < 0.001, MD-HAQ 0.8 versus 0.9; P = 0.01) than nonrespondents (n = 192 [38%]). The respondents with a non-VA provider (n = 130 [41%]) were older (71 versus 68 years; P = 0.001) and had more education (14 versus 13 years; P = 0.021) than nondual-care users. Only 6% of respondents reported having a non-VA rheumatologist, with 2% receiving a non-VA prescribed biologic agent or disease-modifying antirheumatic drug. CONCLUSION In this study, VA beneficiaries with RA had lower dual-care utilization than previously reported for the general VA population, with few patients receiving dual rheumatology care or non-VA RA medications. This survey suggests that most US veterans with RA who access VA care use the VA as their primary source of arthritis care.
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Affiliation(s)
- Pascale Schwab
- VA Portland Health Care System; Oregon Health & Science University, Portland, OR, USA
| | - Harlan Sayles
- Veterans Affairs (VA) Nebraska-Western Iowa Health Care System; Division of Rheumatology, Nebraska Arthritis Outcomes Research Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Debra Bergman
- Veterans Affairs (VA) Nebraska-Western Iowa Health Care System; Division of Rheumatology, Nebraska Arthritis Outcomes Research Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Grant W. Cannon
- VA Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kaleb Michaud
- Veterans Affairs (VA) Nebraska-Western Iowa Health Care System; Division of Rheumatology, Nebraska Arthritis Outcomes Research Center, University of Nebraska Medical Center, Omaha, NE, USA
- National Data Bank for Rheumatic Diseases, Wichita, KS, USA
| | - Ted R. Mikuls
- Veterans Affairs (VA) Nebraska-Western Iowa Health Care System; Division of Rheumatology, Nebraska Arthritis Outcomes Research Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jennifer Barton
- VA Portland Health Care System; Oregon Health & Science University, Portland, OR, USA
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Harnett J, Gerber R, Gruben D, Koenig AS, Chen C. Evaluation of Real-World Experience with Tofacitinib Compared with Adalimumab, Etanercept, and Abatacept in RA Patients with 1 Previous Biologic DMARD: Data from a U.S. Administrative Claims Database. J Manag Care Spec Pharm 2016; 22:1457-1471. [PMID: 27882833 PMCID: PMC10397820 DOI: 10.18553/jmcp.2016.22.12.1457] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Real-world data comparing tofacitinib with biologic disease-modifying antirheumatic drugs (bDMARDs) are limited. OBJECTIVE To compare characteristics, treatment patterns, and costs of patients with rheumatoid arthritis (RA) receiving tofacitinib versus the most common bDMARDs (adalimumab [ADA], etanercept [ETN], and abatacept [ABA]) following a single bDMARD in a U.S. administrative claims database. METHODS This study was a retrospective cohort analysis of patients aged ≥ 18 years with an RA diagnosis (ICD-9-CM codes 714.0x-714.4x; 714.81) and 1 previous bDMARD filling ≥ 1 tofacitinib or bDMARD claim in the Truven MarketScan Commercial and Medicare Supplemental claims databases (November 1, 2012-October 31, 2014). Monotherapy was defined as absence of conventional synthetic DMARDs within 90 days post-index. Persistence was evaluated using a 60-day gap. Adherence was assessed using proportion of days covered (PDC). RA-related total, pharmacy, and medical costs were evaluated in the 12-month pre- and post-index periods. Treatment patterns and costs were adjusted using linear models including a common set of clinically relevant variables of interest (e.g., previous RA treatments), which were assessed separately using t-tests and chi-squared tests. RESULTS Overall, 392 patients initiated tofacitinib; 178 patients initiated ADA; 118 patients initiated ETN; and 191 patients initiated ABA. Tofacitinib patients were older versus ADA patients (P = 0.0153) and had a lower proportion of Medicare supplemental patients versus ABA patients (P = 0.0095). Twelve-month pre-index bDMARD use was greater in tofacitinib patients (77.6%) versus bDMARD cohorts (47.6%-59.6%). Tofacitinib patients had greater 12-month pre-index RA-related total costs versus bDMARD cohorts (all P < 0.0001) and greatest index use of monotherapy (P = 0.0080 vs. ABA). A similar (all P > 0.10) proportion of patients were persistent with tofacitinib (42.6%) versus ADA (37.6%), ETN (42.4%), and ABA (43.5%). Mean PDC was 0.55 for tofacitinib versus 0.57 (ADA), 0.59 (ETN), and 0.44 (ABA; P = 0.0003). Adjusted analyses generated similar findings to the unadjusted treatment patterns. Tofacitinib had lower adjusted 12-month post-index mean RA-related total costs ($23,568) versus ADA ($29,278; P < 0.0001), ETN ($26,885; P = 0.0248), and ABA ($30,477; P < 0.0001). CONCLUSIONS In this study, tofacitinib was more commonly used as monotherapy and yielded at least comparable persistence and adherence with lower adjusted mean RA-related total costs versus ADA, ETN, and ABA. Further analysis is warranted given the greater 12-month pre-index bDMARD use and RA-related costs for tofacitinib versus bDMARDs. DISCLOSURES This study was sponsored by Pfizer. Harnett, Gerber, Gruben, Koenig, and Chen are employees and shareholders of Pfizer. Some data reported in this manuscript have been previously presented at the Academy of Managed Care Nexus 2015; Orlando, Florida; October 26-29, 2015, and was submitted in abstract form to the European League Against Rheumatism Congress; London, United Kingdom; June 8-11, 2016. All authors were involved in the conception and design of this study. Harnett and Gruben were involved in data collection and analysis. All authors interpreted the data, critically reviewed and revised the manuscript, and read and approved the final manuscript.
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Gu T, Shah N, Deshpande G, Tang DH, Eisenberg DF. Comparing Biologic Cost Per Treated Patient Across Indications Among Adult US Managed Care Patients: A Retrospective Cohort Study. Drugs Real World Outcomes 2016; 3:369-381. [PMID: 27757919 PMCID: PMC5127933 DOI: 10.1007/s40801-016-0093-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The relative cost of biologics in the treatment of autoimmune disorders, including rheumatoid arthritis, psoriatic arthritis, psoriasis, and ankylosing spondylitis, is a key consideration for managed care payers. OBJECTIVES Our objective was to estimate biologic costs and treatment patterns in US managed care patients with rheumatoid arthritis, psoriatic arthritis, psoriasis, and/or ankylosing spondylitis. METHODS This retrospective study used administrative claims data from the HealthCore Integrated Research Database (HIRDSM) for adults with rheumatoid arthritis, psoriatic arthritis, psoriasis, and/or ankylosing spondylitis who received abatacept, adalimumab, certolizumab, etanercept, golimumab, infliximab, rituximab, tocilizumab, or ustekinumab between 1 July 2009 and 31 January 2013. Biologic costs (based on drug utilization) and treatment patterns (discontinued, restarted after a >45-day gap, switched to another biologic, or persisted without switching or stopping) were analyzed for the first year post-index. RESULTS Most of the 24,460 patients received etanercept (48 %), adalimumab (29 %), or infliximab (12 %) as the index biologic. On the index date, 44 % were new to biologic therapy and 56 % were continuing biologic therapy. Biologic cost per treated patient for 1 year was as follows: etanercept $US24,859, adalimumab $US26,537, and infliximab $US26,468. Treatment patterns across indications for etanercept, adalimumab, and infliximab were as follows: persistent (52, 49, 67 %), restarted (23, 21, 12 %), switched (12, 13, 11 %), and discontinued (14, 18, 10 %). CONCLUSIONS These findings from a large health benefits organization in the USA are similar to those of several previous cost analyses assessing different populations, which demonstrates the external validity of the results from the previous studies, both over time and across large populations.
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Affiliation(s)
- Tao Gu
- HealthCore, Inc., 123 S. Justison Street, Suite 200, Wilmington, DE, 19801-5134, USA.
| | | | - Gaurav Deshpande
- HealthCore, Inc., 123 S. Justison Street, Suite 200, Wilmington, DE, 19801-5134, USA
| | | | - Debra F Eisenberg
- HealthCore, Inc., 123 S. Justison Street, Suite 200, Wilmington, DE, 19801-5134, USA
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Lu CC, Leng J, Cannon GW, Zhou X, Egger M, South B, Burningham Z, Zeng Q, Sauer BC. The use of natural language processing on narrative medication schedules to compute average weekly dose. Pharmacoepidemiol Drug Saf 2016; 25:1414-1424. [PMID: 27633139 DOI: 10.1002/pds.4086] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 07/29/2016] [Accepted: 08/01/2016] [Indexed: 11/09/2022]
Abstract
PURPOSE Medications with non-standard dosing and unstandardized units of measurement make the estimation of prescribed dose difficult from pharmacy dispensing data. A natural language processing tool named the SIG extractor was developed to identify and extract elements from narrative medication instructions to compute average weekly doses (AWDs) for disease-modifying antirheumatic drugs. The goal of this paper is to evaluate the performance of the SIG extractor. METHOD This agreement study utilized Veterans Health Affairs pharmacy data from 2008 to 2012. The SIG extractor was designed to extract key elements from narrative medication schedules (SIGs) for 17 select medications to calculate AWD, and these medications were categorized by generic name and route of administration. The SIG extractor was evaluated against an annotator-derived reference standard for accuracy, which is the fraction of AWDs accurately computed. RESULTS The overall accuracy was 89% [95% confidence interval (CI) 88%, 90%]. The accuracy was ≥85% for all medications and route combinations, except for cyclophosphamide (oral) and cyclosporine (oral), which were 79% (95%CI 72%, 85%) and 66% (95%CI 58%, 73%), respectively. CONCLUSIONS The SIG extractor performed well on the majority of medications, indicating that AWD calculated by the SIG extractor can be used to improve estimation of AWD when dispensed quantity or days' supply is questionable or improbable. The working model for annotating SIGs and the SIG extractor are generalized and can easily be applied to other medications. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Chao-Chin Lu
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA.,University of Utah, Salt Lake City, UT, USA
| | - Jianwei Leng
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA.,University of Utah, Salt Lake City, UT, USA
| | - Grant W Cannon
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA.,University of Utah, Salt Lake City, UT, USA
| | - Xi Zhou
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA.,University of Utah, Salt Lake City, UT, USA
| | | | - Brett South
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA.,University of Utah, Salt Lake City, UT, USA
| | - Zach Burningham
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Qing Zeng
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Brian C Sauer
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA.,University of Utah, Salt Lake City, UT, USA
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Cannon GW, DuVall SL, Haroldsen CL, Caplan L, Curtis JR, Michaud K, Mikuls TR, Reimold A, Collier DH, Joseph GJ, Harrison DJ, Sauer BC. Clinical Outcomes and Biologic Costs of Switching Between Tumor Necrosis Factor Inhibitors in US Veterans with Rheumatoid Arthritis. Adv Ther 2016; 33:1347-59. [PMID: 27352377 PMCID: PMC4969320 DOI: 10.1007/s12325-016-0371-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Indexed: 11/26/2022]
Abstract
Introduction The purpose of this study was to evaluate clinical outcomes and drug/administration costs of treatment with tumor necrosis factor inhibitor (TNFi) agents in US veterans with rheumatoid arthritis (RA) initiating TNFi therapy. The analysis compared patients initiating and continuing a single TNFi with patients who subsequently switched to a different TNFi. Methods Data from patients enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry who initiated treatment with adalimumab, etanercept, or infliximab from 2003 to 2010 were analyzed. Outcomes included duration of therapy, Disease Activity Score based on 28 joints (DAS28), and direct drug and drug administration costs. Results Of 563 eligible patients, 262 initiated a single TNFi therapy, 142 restarted their initial TNFi after a ≥90-day gap in treatment (interrupted therapy), and 159 switched to a different TNFi. Patients who switched had higher mean DAS28 before starting TNFi therapy than patients with single or interrupted therapy: 5.3 vs 4.5 or 4.6, respectively. Mean duration of the first course was 34.3 months for single therapy, 18.3 months for interrupted therapy, and 17.7 months for switched therapy. Mean post-treatment DAS28 was highest for patients who switched TNFi. Mean annualized costs for first course were $13,800 for single therapy, $13,200 for interrupted therapy, and $14,200 for switched therapy; mean annualized costs for second course were $12,800 for interrupted therapy and $15,100 for switched therapy. Conclusion Patients who switched TNFi had higher pre-treatment DAS28 and higher overall costs than patients who received the same TNFi as either single or interrupted therapy. Funding This research was funded by Immunex Corp., a fully owned subsidiary of Amgen Inc., and by VA HSR&D Grant SHP 08-172.
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Affiliation(s)
- Grant W Cannon
- Veterans Affairs Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Scott L DuVall
- Veterans Affairs Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Candace L Haroldsen
- Veterans Affairs Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Liron Caplan
- Denver VA and University of Colorado School of Medicine, Denver, CO, USA
| | | | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, NE, USA
- National Data Bank for Rheumatic Diseases, Wichita, KS, USA
| | - Ted R Mikuls
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, NE, USA
| | - Andreas Reimold
- Dallas VA and University of Texas Southwestern, Dallas, TX, USA
| | | | | | | | - Brian C Sauer
- Veterans Affairs Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA
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Sauer BC, Teng CC, He T, Leng J, Lu CC, Walsh JA, Shah N, Harrison DJ, Tang DH, Cannon GW. Treatment patterns and annual biologic costs in US veterans with rheumatic conditions or psoriasis. J Med Econ 2016; 19:34-43. [PMID: 26337538 DOI: 10.3111/13696998.2015.1086774] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine annual biologic drug and administration costs to the US Veterans Health Administration (VHA) per treated patient with rheumatoid arthritis (RA), psoriasis (PsO), psoriatic arthritis (PsA), or ankylosing spondylitis (AS) who received abatacept, adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, tocilizumab, or ustekinumab. METHODS Adults with at least one biologic claim between January 1, 2008 and December 31, 2011 were included. Evidence of enrollment in the VHA was required from 365 days before (pre-index) to 360 days after (post-index) the date of the first biologic claim (index date). Included patients had pre-index diagnoses of RA, PsO, PsA, and/or AS. Drug costs were from Federal Supply Schedule or 'Big Four' in November 2014. Administration costs were VHA fixed costs for infused ($169) and subcutaneous ($25) biologics. RESULTS Of the 20,465 patients in the analysis, 10,711 received etanercept, 7838 received adalimumab, and 1196 received infliximab as the index biologic. In these patients, across all uses studied, the VHA incurred greater annual cost per treated patient for infliximab ($18,066) compared with adalimumab ($16,523) and etanercept ($16,526). In the first year post-index, ∼80% of patients were either persistent on these index biologics or re-started these index biologics after a ≥45-day treatment gap. Other biologics comprised <5% of the study population, with sample sizes ranging from 3-374 patients each. Cost by indication for biologics used by >20 patients ranged from $15,056 (etanercept) to $17,050 (abatacept) for RA; $16,697 (adalimumab) to $33,163 (ustekinumab) for PsO; $15,035 (etanercept) to $20,465 (infliximab) for PsA; and $14,239 (etanercept) to $18,536 (infliximab) for AS. LIMITATIONS The model was limited to the VHA. Results for biologics other than adalimumab, etanercept, and infliximab were difficult to interpret because of small sample sizes. CONCLUSIONS Infliximab has higher cost to the VHA than adalimumab or etanercept.
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Affiliation(s)
- Brian C Sauer
- a a Health Services Research and Development (IDEAS Center), SLC VA Medical Center , Salt Lake City, UT, USA, and Epidemiology, University of Utah , Salt Lake City , UT , USA
| | - Chia-Chen Teng
- a a Health Services Research and Development (IDEAS Center), SLC VA Medical Center , Salt Lake City, UT, USA, and Epidemiology, University of Utah , Salt Lake City , UT , USA
| | - Tao He
- a a Health Services Research and Development (IDEAS Center), SLC VA Medical Center , Salt Lake City, UT, USA, and Epidemiology, University of Utah , Salt Lake City , UT , USA
| | - Jianwei Leng
- a a Health Services Research and Development (IDEAS Center), SLC VA Medical Center , Salt Lake City, UT, USA, and Epidemiology, University of Utah , Salt Lake City , UT , USA
| | - Chao-Chin Lu
- a a Health Services Research and Development (IDEAS Center), SLC VA Medical Center , Salt Lake City, UT, USA, and Epidemiology, University of Utah , Salt Lake City , UT , USA
| | - Jessica A Walsh
- b b Rheumatology, SLC VA Medical Center and University of Utah , Salt Lake City , UT , USA
| | - Neel Shah
- c c Global Health Economics, Amgen Inc. , Thousand Oaks , CA , USA
| | - David J Harrison
- c c Global Health Economics, Amgen Inc. , Thousand Oaks , CA , USA
| | - Derek H Tang
- c c Global Health Economics, Amgen Inc. , Thousand Oaks , CA , USA
| | - Grant W Cannon
- b b Rheumatology, SLC VA Medical Center and University of Utah , Salt Lake City , UT , USA
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Sangiorgi D, Benucci M, Nappi C, Perrone V, Buda S, Degli Esposti L. Drug usage analysis and health care resources consumption in naïve patients with rheumatoid arthritis. Biologics 2015; 9:119-27. [PMID: 26604680 PMCID: PMC4642803 DOI: 10.2147/btt.s89286] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The use of biologic agents has revolutionized the management of rheumatoid arthritis (RA) in the past 2 decades. These biologic agents directly target molecules and cells involved in the pathogenesis of RA. The purpose of this study was to assess the usage of biologic agents in terms of persistence to treatment, dose escalation, and consumption of health care resources (hospitalizations, drugs, and outpatients service) in the real clinical practice in naïve patients with RA. METHODS We conducted a real-world, retrospective, observational cohort study based on data obtained from administrative databases of three Local Health Units in Italy. The population included adults diagnosed with RA who had at least one prescription between January 1, 2009 and December 31, 2011, for a biologic that was approved for treatment of RA. The patients were followed for 12 months after enrollment. The clinical characteristics of the patients enrolled in this study were also investigated in the 1-year period before the index date. The main and secondary endpoints were evaluated only in biologic-naïve patients without switches. The overall health care costs for patients were evaluated. RESULTS A total of 594 patients met the study criteria (mean age 53.5±13.5, female:male ratio =3:1). Thirty-nine percent received etanercept, 25% adalimumab, 14% infliximab, 10% abatacept, 9% tocilizumab, and 3% golimumab. After 1 year of observation, patients showed similar use of other RA-related medication. For the naïve patients without switches, the persistence levels were: 78% for etanercept, 72% for tocilizumab, 71% for adalimumab, 69% for infliximab, and 64% for abatacept. For all agents, dose escalation was 21.4% for infliximab, 11.5% for adalimumab, 5.6% for abatacept, 4% for tocilizumab, and 3.8% for etanercept. The annual costs per treated patients were €12,803 for adalimumab, €11,924 for etanercept, €11,830 for tocilizumab, €11,201 for infliximab, and €10,943 for abatacept. CONCLUSION The role of biologic therapies in the treatment of RA continues to evolve; our study reflects real-world drug utilization data in adult patients with RA. These observations could be used by decision makers to support formulary decisions, although further research is needed using a larger sample to validate these results.
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Affiliation(s)
- Diego Sangiorgi
- CliCon S.r.l., Health, Economics and Outcomes Research, Ravenna, Italy
| | - Maurizio Benucci
- Unit of Rheumatology, S. Giovanni di Dio Hospital, Florence, Italy
| | | | - Valentina Perrone
- CliCon S.r.l., Health, Economics and Outcomes Research, Ravenna, Italy
| | - Stefano Buda
- CliCon S.r.l., Health, Economics and Outcomes Research, Ravenna, Italy
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Wu N, Bhurke S, Shah N, Harrison DJ. Application of a validated algorithm to estimate the effectiveness and cost of biologics for rheumatoid arthritis in the US pharmacy benefit manager context. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:257-66. [PMID: 25999750 PMCID: PMC4435053 DOI: 10.2147/ceor.s83932] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Several biologic medicines are available to treat rheumatoid arthritis (RA), and they differ in administration method (subcutaneous or intravenous [IV]). We analyzed a pharmacy benefit manager database to estimate claims-based, algorithm-determined effectiveness and cost per effectively treated patient for biologics used to treat RA. METHODS We analyzed the Medco Health Solutions pharmacy benefit manager database to identify patients with one or more claims for a biologic used to treat RA from 2007 to 2012. The first observed claim defined the index date, the previous 180 days were the pre-index period, and follow-up was 365 days after the index date. Effectiveness of a biologic was determined by a validated, published algorithm designed for use in claims database analyses. Cost per effectively treated patient as determined by the algorithm was calculated as the total annual cost of the biologic therapy divided by the number of effectively treated patients. Analyses were conducted for subcutaneous, IV, and individual biologics. RESULTS The analysis population was 1,090 patients (subcutaneous: 785, IV: 305; etanercept: 440, adalimumab: 345, infliximab: 201, abatacept: 104). The mean age was 49.7±9.4 years, and 78% of the patients were female. Effectiveness according to the algorithm was higher in subcutaneous (36%) versus IV biologics (23%; P<0.001), and in etanercept (36%) versus infliximab (22%; P<0.001) and versus abatacept (24%; P=0.02). Etanercept and adalimumab were similar (35%; P=0.77). The cost per effectively treated patient according to the algorithm was $64,738 for subcutaneous biologics, $80,408 for IV biologics, $62,841 for etanercept, $67,226 for adalimumab, $90,696 for infliximab, and $62,303 for abatacept. CONCLUSION Effectiveness according to a validated, claims-based algorithm was higher in subcutaneous versus IV biologics. Cost per effectively treated patient according to the algorithm was approximately $16,000 less in subcutaneous versus IV biologics.
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Affiliation(s)
- Ning Wu
- Health Economics and Epidemiology, Evidera, Lexington, MA, USA
| | - Sharvari Bhurke
- Health Economics and Epidemiology, Evidera, Lexington, MA, USA
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Martinez-Cutillas J, Alerany-Pardo C, Borrás-Blasco J, Broto-Sumalla A, Burgos-SanJosé A, Climent-Bolta C, Escudero-Vilaplana V, Fernández-Fuente MA, Ferrit-Martin M, Gómez-Germá P, Martínez-Sesmero JM, Mayorga-Pérez J, Menchén-Viso B, Merino-Alonso J, Polache-Vengud J, Sánchez-Guerrero A. The use of adalimumab, etanercept, golimumab and infliximab in rheumatic pathologies: variation between label dosage and real-world use. Expert Rev Pharmacoecon Outcomes Res 2015; 15:851-8. [PMID: 25972066 DOI: 10.1586/14737167.2015.1044514] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Rheumatoid arthritis (AR), psoriatic arthritis (PSA) and ankylosing spondylitis (AS) are autoimmune systemic diseases characterized by inflammation, pain and joint degeneration. The objective of this study is to evaluate, under the actual conditions of use, dosing patterns of adalimumab, etanercept, golimumab and infliximab in these pathologies, and compare them with the label regimens recommended, as well as evaluating the financial implications of these regimen modifications. The study population included all adult patients diagnosed with RA, PSA or AS who had been treated with adalimumab, etanercept, golimumab and infliximab for at least 6 months between 1 January 2011 and 31 December 2013. The main variable of this study was to assess the dose dispensed for drugs administered subcutaneously and the dose prepared/administered for drugs administered intravenously, and the annual costs of the treatment. A total of 5,428 episodes were included. The mean weekly dose was lower than the standard dose in the three pathologies studied in the patients treated with adalimumab and etanercept (84.3% vs 81.2% for RA, 85.0% vs 78.0% for PSA and 87.8% vs 81.6% for AS). The drugs with highest dose optimization in RA are etanercept (46.3%) followed by adalimumab (46%); however, the highest percentage of patients with major dose optimization corresponds to etanercept (11.6%). Both in the PA and the AS group, we also observed that etanercept is the drug more optimized, corresponding to 53.9 and 43% of patients, respectively. By contrast, 48.5% of patients with RA treated with infliximab required dose intensification; however, infliximab dose intensification in PSA and AS is not so pronounced. The practice of optimization of dose regimens in patients with rheumatic diseases under treatment with anti-TNFα is spreading among professionals, resulting in annual cost reduction in the treatment of rheumatic arthropathies. However, long term follow-up will be necessary to assess the influence of this optimization on health outcomes.
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Affiliation(s)
| | | | - Joaquín Borrás-Blasco
- b 2 Hospital de Sagunto, Pharmacy, Avda Ramon y Cajal s/n, Sagunto 46520 (Valencia), Spain
| | | | | | | | | | | | | | | | | | - Jesús Mayorga-Pérez
- k 11 Hospital Universitario Marques de Valdecilla, Pharmacy, Santander, Spain
| | | | - Javier Merino-Alonso
- m 13 Hospital Universitario Ntra Sra de Candelaria, Pharmacy, Santa Cruz de Tenerife, Spain
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Nelson SD, Lu CC, Teng CC, Leng J, Cannon GW, He T, Zeng Q, Halwani A, Sauer B. The use of natural language processing of infusion notes to identify outpatient infusions. Pharmacoepidemiol Drug Saf 2014; 24:86-92. [PMID: 25402257 DOI: 10.1002/pds.3720] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 07/25/2014] [Accepted: 09/05/2014] [Indexed: 11/10/2022]
Abstract
PURPOSE Outpatient infusions are commonly missing in Veterans Health Affairs (VHA) pharmacy dispensing data sets. Currently, Healthcare Common Procedure Coding System (HCPCS) codes are used to identify outpatient infusions, but concerns exist if they correctly capture all infusions and infusion-related data such as dose and date of administration. We developed natural language processing (NLP) software to extract infusion information from medical text infusion notes. The objective was to compare the sensitivity of three approaches to identify infliximab administration dates and infusion doses against a reference standard established from the Veterans Affairs rheumatoid arthritis (VARA) registry. METHODS We compared the sensitivity and positive predictive value (PPV) of NLP to that of HCPCS codes in identifying the correct date and dose of infliximab infusions against a human extracted reference standard. RESULTS The sensitivity was 0.606 (0.585-0.627) for HCPCS alone, 0.858 (0.842-0.873) for NLP alone, and 0.923 (0.911-0.934) for the two methods combined, with a PPV of 0.735 (0.716-0.754), 0.976 (0.969-0.983), and 0.957 (0.948-0.965) for each method, respectively. The mean dose of infliximab was 433 mg in the reference standard, 337 mg from HCPCS, 434 mg from NLP, and 426 mg from the combined method. CONCLUSIONS HCPCS codes alone are not sufficient to accurately identify infliximab infusion dates and doses in the VHA system. The use of NLP significantly improved the sensitivity and PPV for estimating infusion dates and doses, especially when combined with HCPCS codes.
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Affiliation(s)
- Scott D Nelson
- George E. Whalen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA; University of Utah, Salt Lake City, UT, USA
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