An indirect comparison and cost per responder analysis of adalimumab, methotrexate and apremilast in the treatment of methotrexate-naïve patients with psoriatic arthritis

The Efficacy and Safety of Apremilast in the Management of Psoriatic Arthritis: A Systematic Review and Meta-Analysis

Psoriasis is a chronic autoimmune inflammatory skin disease that is associated with other conditions, one of them being psoriatic arthritis (PsA). Apremilast, a phosphodiesterase-4 inhibitor, displayed promising results in multiple trials for patients with PsA. This systematic review and meta-analysis aims to showcase its efficacy and safety when compared to placebo. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was adopted after registration on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023476245). Four databases were systematically searched from their inception until October 25, 2023. As a result, five randomized controlled trials were included with 1,849 participants, after thorough screening. The primary efficacy endpoint evaluated in this meta-analysis was the American College of Rheumatology Response Criteria 20 (ACR20). The results significantly favored apremilast (risk ratio [RR] = 1.92, 95% confidence interval [CI] 1.66-2.21; P < 0.00001; I2= 0%) as opposed to placebo. Similarly, secondary efficacy endpoints, ACR50 (RR = 2.34, 95% CI 1.79-3.06; P < 0.00001; I2 = 0%), ACR70 (RR = 2.89, 95% CI 1.62-5.18; P = 0.0003; I2 = 0%), and the Health Assessment Questionnaire and Disability Index (HAQ-DI; standardized mean difference [SMD] = -0.26, 95% CI -0.34 to -0.17; P < 0.00001; I2 = 0%) were also in significant favor of apremilast. However, apremilast had a higher occurrence of gastrointestinal adverse events than placebo (RR = 1.21, 95% CI 1.12-1.30; P < 0.00001; I2 = 19%). To conclude, apremilast shows promising efficaciousness with some nonserious side effects when compared to placebo, but further trials are needed for comparison with other management lines.

Biologic Initiation Rate in Systemic-Naïve Psoriatic Arthritis Patients Starting Treatment with Apremilast vs Methotrexate: 1-Year Retrospective Analysis of a US Claims Database

Purpose

To compare the rate of biologic initiation after commencing treatment with apremilast (APR) vs methotrexate (MTX), in systemic-naïve patients with psoriatic arthritis (PsA).

Patients and Methods

Systemic-naïve patients with PsA who started treatment with either APR or MTX between 01/01/2015 and 12/31/2018 were analyzed using claims data from the IBM^® MarketScan^® Commercial and Medicare Supplemental databases (2014-2019). PsA patients were identified via diagnosis codes; the first prescription date for APR or MTX was the index date. Patient demographics, clinical characteristics, healthcare utilization during the year pre-index (baseline) and the year post-index (follow-up), and median time to biologic initiation were reported descriptively. The rates and risk of biologic initiation during follow-up were compared between APR and MTX users by logistic and Cox regressions, respectively. Models were adjusted for demographics, clinical and utilization measures during the baseline period.

Results

A total of 2116 patients with PsA newly treated with APR (n = 534) or MTX (n = 1582) were identified. Mean age was similar (50.5 vs 50.4; P = 0.938), and proportion of females was higher for APR vs MTX users (59.4% vs 54.0%; P = 0.031). Mean time to biologic initiation among patients who initiated during follow-up was 194.1 vs 138.7 days between APR vs MTX users (P < 0.001). After adjusting for confounders, the likelihood of biologic initiation was 58% lower (OR, 0.42 [95% CI, 0.32-0.54]; P < 0.001) with APR, with a significantly lower predicted rate of biologic initiation among APR users when compared to MTX users during follow-up (20.0% [95% CI, 16.6-23.9%] vs 37.5% [95% CI, 35.0-40.1%]). Additionally, APR users had a lower risk of biologic initiation than MTX users (HR, 0.46 [95% CI, 0.37-0.57]; P < 0.001) during the 1-year follow-up.

Conclusion

Systemic-naïve patients with PsA have a lower rate of, and longer time to, biologic initiation over one-year following APR initiation, compared to those initiating MTX.

2021 clinical practice guidelines for the diagnosis, treatment, and follow-up of patients with peripheral spondyloarthritis. Colombian Association of Rheumatology

BACKGROUND

Peripheral spondyloarthritis is a chronic inflammatory disease in which clinical presentation is related to the presence of arthritis, enthesitis and/or dactylitis. This term is used interchangeably with some of its subtypes such as psoriatic arthritis, reactive arthritis, and undifferentiated spondyloarthritis.

OBJECTIVE

To develop and formulate a set of specific recommendations based on the best available evidence for the diagnosis, treatment and monitoring of adult patients with peripheral spondyloarthritis.

METHODS

A working group was established, clinical questions were formulated, outcomes were graded, and a systematic search for evidence was conducted. The guideline panel was multidisciplinary (including patient representatives) and balanced. Following the formal expert consensus method, the GRADE methodology "Grading of Recommendations Assessment, Development and Evaluation" was used to assess the quality of the evidence and generate the recommendations. The Clinical Practice Guideline includes ten recommendations; related to monitoring of disease activity (n = 1) and treatment (n = 9).

RESULTS

In patients with peripheral spondyloarthritis, the use of methotrexate or sulfasalazine as the first line of treatment is suggested, and local injections of glucocorticoids is recommended conditionally. In patients with failure to cDMARDs, an anti TNFα or an anti IL17A is recommended. In case of failure to bDMARDs, it is suggested to use another bDMARD or JAK inhibitor. In patients with peripheral spondyloarthritis associated to inflammatory bowel disease, it is recommended to start treatment with cDMARDs; in the absence of response, the use of an anti TNFα over an anti-IL-17 or an anti-IL-12-23 is recommended as a second line of treatment. In patients with psoriatic arthritis, the combined use of methotrexate with bDMARD is conditionally recommended for optimization of dosing. To assess disease activity in Psoriatic Arthritis, the use of DAPSA or MDA is suggested for patient monitoring.

CONCLUSIONS

This set of recommendations provides an updated guide on the diagnosis and treatment of peripheral spondyloarthritis.

Apremilast and its role in psoriatic arthritis

Psoriatic arthritis (PsA) is a seronegative inflammatory arthritis often observed in patients with skin psoriasis. Treatment of PsA, especially peripheral PsA, has typically relied on disease-modifying anti-rheumatic agents (DMARDs); however, these agents have limited efficacy and considerable associated toxicity. More recently, monoclonal antibodies (biologic agents) have revolutionized management of immune-mediated diseases; however, these therapies carry a high cost and require parenteral administration. Apremilast, a novel oral DMARD, was approved by the European Union for psoriatic arthritis in 2015. Apremilast inhibits the function of phosphodiesterase-4, a regulator of cyclic adenosine monophosphate, leading to a broad inhibition of proinflammatory mediators and subsequent reduction in tumour necrosis factor-alpha (TNF-α) response. The PALACE and ACTIVE trials, phase III randomized controlled trials for apremilast, showed that apremilast is effective at improving various clinical and patient-reported outcome measures for psoriatic arthritis in both DMARD-naïve and DMARD-experienced PsA patients. Efficacy was limited in patients with previous biologic DMARD failure and the overall efficacy of apremilast appears to be less than biologics agents, though no head-to-head trials exist comparing apremilast to biologic DMARDs. Apremilast is generally well tolerated, with short-lived gastrointestinal side effects being the most commonly reported adverse events. Guidelines suggest a trial of apremilast in patients who have failed traditional oral DMARDs and for whom, biologics are contraindicated. More studies directly comparing apremilast to conventional DMARDs and biologic DMARDs are needed and will be crucial in informing clinical and economic decisions about apremilast role in management of PsA.

Treatment Switch Patterns and Healthcare Costs in Biologic-Naive Patients with Psoriatic Arthritis

Introduction

We compared treatment switch patterns and healthcare costs among biologic-naive patients with psoriatic arthritis (PsA) who initiated apremilast or biologics.

Methods

A 1:2 propensity score match was used to adjust administrative claims data for adults initiating apremilast or biologics from January 1, 2014, to September 30, 2016, for possible selection bias. Patients had at least 12 months of pre- and post-index continuous enrollment in the Optum Clinformatics™ Data Mart database. Outcomes included switch frequency, days to switch, adherence on index treatment, and healthcare costs (total and per patient per month). Switch rate was defined as the proportion of patients who switched to a new treatment after initiation of the index treatment, and days to switch was calculated as the days between initiation of the index treatment and initiation of the new treatment. Adherence was calculated using the proportion of days covered and the medication possession ratio. The t test and chi-square, Kaplan–Meier, and Wilcoxon rank-sum tests were used to evaluate differences between the cohorts.

Results

Patient characteristics and switch rates were similar between the matched apremilast (n = 170) and biologic (n = 327) cohorts. After matching, patient characteristics were similar between the matched cohorts. The 12-month switch rates were similar for patients initiating apremilast versus those on biologics (17.7% vs. 25.1%, P = 0.06). This trend was similar at 6 months (7.7% vs. 13.2%, P = 0.07) and 18 months (24.4% vs. 29.3%, P = 0.33). Regardless of treatment switching, 12-month total healthcare costs were lower with apremilast versus biologics (all: $28,423 vs. $41,178, P < 0.0001; switched: $39,803 vs. $51,517, P = 0.0040; did not switch: $25,984 vs. $37,717, P < 0.0001).

Conclusions

Biologic-naive patients with PsA who initiated apremilast had switch rates similar to biologic users and significantly lower healthcare costs, regardless of treatment switching.

Psoriatic arthritis (PsA) is a chronic inflammatory disease that affects an estimated 30% of psoriasis patients who use systemic therapy. Symptoms of PsA, such as joint swelling and tenderness, can be painful and disabling and may worsen quality of life. PsA can also impart a substantial economic burden. Treatment for moderate to severe PsA often involves the use of systemic oral medications (e.g., conventional systemic treatments such as methotrexate or targeted systemic treatments such as apremilast) or biologic therapy given by injection or infusion. Because PsA symptoms and responses to treatment can vary, patients may switch treatments over time. More research is needed to better understand how switching treatments affects healthcare costs among patients starting treatment with apremilast or a biologic for PsA. This study compared treatment switching and healthcare costs among patients with PsA who had never been treated with a biologic and who started treatment with apremilast or a biologic for PsA. Rates of treatment switching at 12 months were similar for patients starting treatment with apremilast versus those starting a biologic. Patients starting treatment with apremilast had significantly lower total healthcare costs compared with those starting a biologic, even if they later switched to a biologic. Healthcare costs calculated per patient per month (PPPM) were also lower with apremilast versus biologics, driven by lower PPPM pharmacy costs. These findings suggest that starting treatment with apremilast may be an effective and cost-effective strategy for managing PsA, even for patients who later switch to a biologic.

Comparative Efficacy and Safety of Dupilumab and Benralizumab in Patients with Inadequately Controlled Asthma: A Systematic Review

No head-to-head trials have compared the efficacy and safety between the licensed dosage and administration dosage of dupilumab and benralizumab for inadequately controlled asthma. We conducted an indirect treatment comparison to estimate differences in the efficacy and safety between dupilumab and benralizumab for inadequately controlled asthma using the Bayesian approach. The primary efficacy endpoint was annual exacerbation rate (AER). A subgroup analysis by blood eosinophil count was also performed. The primary safety endpoint was the incidence of any adverse events (AAEs). The results demonstrate that there was no significant difference in the AER between dupilumab and benralizumab in overall patients and the subgroup with the blood eosinophil count of <150. However, the AER was significantly lower in the dupilumab group than in the benralizumab group in the subgroup with a blood eosinophil count of ≥150 but <300, and ≥300 with the rate ratio and 95% credible interval of 0.51 (0.29–0.92) and 0.58 (0.39–0.84), respectively. There was no significant difference in the AAEs between the dupilumab and benralizumab groups. This indirect treatment comparison indicates that dupilumab is superior to benralizumab in patients with inadequately controlled asthma having higher blood eosinophil counts. A direct comparison is required to provide definitive evidence. Systematic Review Registration: UMIN-CTR no. UMIN000036256.

A criterion-based approach to systematic and transparent comparative effectiveness: a case study in psoriatic arthritis

Aim: Indirect treatment comparisons are used when no direct comparison is available. Comparison networks should satisfy the transitivity assumption, that is, equal likelihood of treatment assignment for a given patient based on comparability of studies. Materials & methods: Seven criteria were evaluated across 18 randomized controlled trials in psoriatic arthritis: inclusion/exclusion criteria, clinical trial design and follow-up, patient-level baseline characteristics, disease severity, prior therapies, concomitant and extended-trial treatment and placebo response differences. Results: Across studies, placebo was a common comparator, and key efficacy end points were reported. Collectively, several potential sources of insufficient transitivity were identified, most often related to trial design and population differences. Conclusion: Potential challenges in satisfying transitivity occur frequently and should be evaluated thoroughly.

Methods to Compare Adverse Events in Twitter to FAERS, Drug Information Databases, and Systematic Reviews: Proof of Concept with Adalimumab

INTRODUCTION

Adverse drug reactions (ADRs) are associated with significant health-related and financial burden, and multiple sources are currently utilized to actively discover them. Social media has been proposed as a potential resource for monitoring ADRs, but drug-specific analytical studies comparing social media with other sources are scarce.

OBJECTIVES

Our objective was to develop methods to compare ADRs mentioned in social media with those in traditional sources: the US FDA Adverse Event Reporting System (FAERS), drug information databases (DIDs), and systematic reviews.

METHODS

A total of 10,188 tweets mentioning adalimumab collected between June 2014 and August 2016 were included. ADRs in the corpus were extracted semi-automatically and manually mapped to standardized concepts in the Unified Medical Language System. ADRs were grouped into 16 biologic categories for comparisons. Frequencies, relative frequencies, disproportionality analyses, and rank ordering were used as metrics.

RESULTS

There was moderate agreement between ADRs in social media and traditional sources. "Local and injection site reactions" was the top ADR in Twitter, DIDs, and systematic reviews by frequency, ranked frequency, and index ranking. The next highest ADR in Twitter-fatigue-ranked fifth and seventh in FAERS and DIDs.

CONCLUSION

Social media posts often express mild and symptomatic ADRs, but rates are measured differently in scientific sources. ADRs in FAERS are reported as absolute numbers, in DIDs as percentages, and in systematic reviews as percentages, risk ratios, or other metrics, which makes comparisons challenging; however, overlap is substantial. Social media analysis facilitates open-ended investigation of patient perspectives and may reveal concepts (e.g. anxiety) not available in traditional sources.

Secukinumab for psoriatic arthritis: comparative effectiveness versus licensed biologics/apremilast: a network meta-analysis

AIM

A network meta-analysis using randomized controlled trial data compared psoriatic arthritis (PsA) outcomes (American College of Rheumatology [ACR], Psoriasis Area Severity Index [PASI] and Psoriatic Arthritis Response Criteria [PsARC] response rates) at 12-16 weeks for secukinumab, adalimumab, apremilast, certolizumab, etanercept, golimumab, infliximab and ustekinumab.

PATIENTS & METHODS

Trials were identified by systematic review. Separate networks were developed for the full-study populations, biologic-naive patients and biologic-experienced patients.

RESULTS

In the full populations, secukinumab, adalimumab, golimumab and infliximab demonstrated the highest ACR response rates. Secukinumab and infliximab demonstrated the highest PASI response rates, and infliximab and etanercept demonstrated the highest PsARC response rates.

CONCLUSION

In the full populations, secukinumab demonstrated good efficacy across all outcomes. All treatments for active PsA included in this comprehensive network meta-analysis demonstrated superiority to placebo.

Apremilast in the treatment of psoriatic arthritis: a perspective review

Apremilast is an orally-active small molecule which inhibits phosphodiesterase-4 (PDE4). Clinical trials have demonstrated its efficacy and safety in psoriatic arthritis (PsA) and psoriasis. Established therapeutic options have variable effectiveness across the different domains of psoriatic disease. Whilst biologic therapies have proven to be of significant benefit to many patients, not all patients respond, and others are not eligible or do not tolerate biologic therapy. We review the mechanism of action, pharmacokinetics and clinical trial data with regards to both efficacy and safety for apremilast and consider where this new treatment may be positioned in the treatment of PsA.

Economic Evaluation of Timely Versus Delayed Use of Tumor Necrosis Factor Inhibitors for Treatment of Psoriatic Arthritis in the US

INTRODUCTION

The present study aimed to evaluate clinical outcomes and costs associated with timely versus delayed use of tumor necrosis factor inhibitors (TNFis) among patients with moderately to severely active psoriatic arthritis (PsA) with and without moderate/severe psoriasis (Ps) from a US payer's perspective.

METHODS

An economic model evaluated PsA patients initially treated with a TNFi (timely TNFi use) or apremilast (delayed TNFi use). Patients without joint (American College of Rheumatology 20%, [ACR20]) improvement either switched TNFis or initiated one. ACR20 responses were evaluated for all patients and skin responses by Psoriasis Area Severity Index 75% (PASI75) for those with concomitant PsA and Ps. Published randomized controlled trials and publicly available databases provided model inputs. Effectiveness measures included 1-year responses and number needed to treat (NNT). Direct costs, costs per responder, and incremental costs per responder were calculated.

RESULTS

After 1 year, timely TNFi-treated patients had higher ACR20 responses (70.4% vs. 59.6%) and lower NNTs (1.42 vs. 1.68) compared with delayed use. Among PsA + Ps patients, timely TNFi use was associated with higher ACR20 + PASI75 responses (41.0% vs. 30.0%) and lower NNTs (2.44 vs. 3.33). Cost per ACR20 responder was higher ($56,492 vs. $52,835) among PsA patients without Ps; with concomitant Ps, cost per ACR20 + PASI75 responder was lower for timely TNFi use ($100,954 vs. $111,686). Incremental costs per responder for timely versus delayed TNFi were $76,823 in PsA and $71,791 in PsA and Ps.

CONCLUSION

Timely use of TNFis is a cost-effective strategy for the management of PsA based on improvements in both joint and/or skin disease.

FUNDING

AbbVie Inc.

Comparative efficacy and incremental cost per responder of methotrexate versus apremilast for methotrexate-naïve patients with psoriasis

BACKGROUND

To our knowledge, no clinical trials directly compare apremilast with methotrexate (the standard of care for initial systemic treatment of psoriasis).

OBJECTIVE

We sought to compare apremilast's relative efficacy with that of methotrexate for moderate to severe psoriasis.

METHODS

An anchor-based indirect comparison was conducted for 75% improvement in Psoriasis Area and Severity Index score from baseline to week 16 (PASI 75) rates for systemic-naïve patients from Efficacy and Safety Trial Evaluating the Effects of apreMilast in psoriasis (ESTEEM) 1 and 2 (apremilast vs placebo) and Comparative study of HumirA vs. Methotrexate vs Placebo In psOriasis patieNts (CHAMPION) (adalimumab vs methotrexate vs placebo) trials. The difference-in-difference in PASI 75 response rates was calculated as the difference between the ESTEEM apremilast and placebo rates and the CHAMPION methotrexate versus placebo rates. Number needed to treat and incremental drug cost per responder were also estimated.

RESULTS

No statistically significant difference was found between apremilast and methotrexate in PASI 75 (risk difference 13.1%; 95% confidence interval -1.8% to 28.0%; P = .09). Number needed to treat with apremilast versus methotrexate to gain 1 additional PASI 75 responder was 7.6. Annual incremental drug cost of this responder was estimated at $187,888.33.

LIMITATIONS

Few trials compare systemic-naïve patients. Only direct medication costs were considered.

CONCLUSIONS

There was no statistical evidence of greater efficacy for apremilast versus methotrexate. The $187,888 incremental cost per PASI 75 may exceed what payers are willing to pay.