Increased risk of venous thromboembolic events with corticosteroid vs biologic therapy for inflammatory bowel disease

BACKGROUND & AIMS

We investigated whether treatment of active inflammatory bowel disease with biologic agents is associated with a reduced risk of venous thromboembolic events (VTEs) compared with corticosteroid therapy.

METHODS

We performed a retrospective analysis of 15,100 adults with inflammatory bowel disease who were identified from the Truven Health MarketScan databases. We analyzed data from patients who received 6 months of continuous medical and prescription coverage before and 12 months after their first diagnosis and had no VTE during the 6 months before they first received biologic or corticosteroid therapy. The outcome assessed was any VTE that occurred during the 12-month follow-up period. A multivariate logistic regression model was used to evaluate the effects of biologic, corticosteroid, and combination therapies (biologics and corticosteroids) on VTE risk.

RESULTS

Three hundred twenty-five VTEs occurred during the study period (in 2.25% of patients receiving only corticosteroids, in 0.44% of patients receiving biologics, and in 2.49% of patients receiving combination therapy). Compared with patients receiving only corticosteroids, the odds ratio for VTE in patients receiving only biologics was 0.21 (95% confidence interval, 0.05-0.87) in the multivariate model, and the odds ratio for VTE in patients on combination therapy was 1.01.

CONCLUSIONS

Compared with treatment with only a biologic agent, corticosteroid therapy is associated with a nearly 5-fold increase in risk for VTE. Combination therapy with corticosteroids and biologic agents was associated with the same risk for VTE as that of corticosteroids alone. Corticosteroids therefore appear to increase risk for VTE.

Adalimumab induces deep remission in patients with Crohn's disease

BACKGROUND & AIMS

Patients with moderate to severe ileocolonic Crohn's disease (CD) who received adalimumab induction and maintenance therapy had greater rates of mucosal healing than patients who received placebo after adalimumab induction therapy in a 52-week trial (EXTend the Safety and Efficacy of Adalimumab Through ENDoscopic Healing). We investigated whether this treatment also induced deep remission-a composite clinical and endoscopic end point.

METHODS

Rates of deep remission, defined as the absence of mucosal ulceration and CD Activity Index scores less than 150, were compared between patients given continuous adalimumab and those given only induction therapy followed by placebo. We assessed the relationships between deep remission and other outcomes among patients who received adalimumab. The outcomes of patients with deep remission were compared with those of patients with only the absence of mucosal ulceration or only clinical remission.

RESULTS

Rates of deep remission were 16% in patients given adalimumab vs 10% in those given placebo (P = .34) at week 12, and 19% vs 0% (P < .001) at week 52. Rates of deep remission were greatest among patients who received adalimumab and had CD for 2 years or less (33% at weeks 12 and 52). At week 52, patients who achieved deep remission at week 12 required significantly fewer adalimumab treatment adjustments, hospitalizations, and CD-related surgeries; had significantly less activity impairment; and had better quality of life and physical function compared with patients not achieving deep remission. Deep remission generally was associated with better outcomes than only an absence of mucosal ulceration; outcomes of patients with deep remission vs only clinical remission were similar. Deep remission was associated with estimated total cost savings of $10,360 (from weeks 12 through 52) compared with lack of deep remission.

CONCLUSIONS

In an exploratory study of patients with moderate to severe ileocolonic CD who received adalimumab induction and maintenance therapy, patients achieving deep remission appeared to have better 1-year outcomes than those not achieving deep remission. These findings should be validated in large, prospective trials. ClinicalTrials.gov number: NCT00348283.

Adalimumab improves patient-reported outcomes and reduces indirect costs in patients with moderate to severe Crohn's disease: results from the CARE trial

BACKGROUND AND AIMS

Crohn's disease negatively affects patients' quality of life and ability to work. We investigated the impact of adalimumab on work productivity, daily activities, and quality of life in an open-label trial (N=945). The population comprised both infliximab-naïve and -exposed patients, including infliximab primary non-responders.

METHODS

Patients received adalimumab induction therapy (160 mg/80 mg at Weeks 0/2), followed by adalimumab 40 mg every other week for up to 20 weeks (patients with flares/non-response could receive 40 mg weekly at/after Week 12). The Work Productivity and Activity Impairment Questionnaire and Short Inflammatory Bowel Disease Questionnaire were assessed. Indirect cost savings were estimated based on the average work productivity improvements at Week 20.

RESULTS

Mean baseline scores indicated severe productivity impairment and poor quality of life. At Week 20, 60% of infliximab-naïve and 47% of infliximab primary non-responders achieved clinically important improvements (≥9 points) on the Short Inflammatory Bowel Disease Questionnaire, and 51% and 43%, respectively, achieved the minimum clinically important difference (improvement ≥7 percentage points) for total work productivity impairment (non-responder imputation). At Week 20, 64% of infliximab-naïve and 55% of infliximab primary non-responders achieved clinically important improvements in total activity impairment. Estimated 20-week total indirect productivity-related cost savings were €3070 per infliximab-naïve patient and €2059 per infliximab-exposed patient.

CONCLUSIONS

Adalimumab therapy significantly improved work productivity and disease-specific quality of life for patients with moderate to severe Crohn's disease. Patients who failed prior infliximab therapy and patients naïve to infliximab benefited from adalimumab, with potentially greater benefits for infliximab-naïve patients (NCT00409617).

Sleep quality and other patient-reported outcomes improve after patients with psoriasis with suboptimal response to other systemic therapies are switched to adalimumab: results from PROGRESS, an open-label Phase IIIB trial

BACKGROUND

Psoriasis is associated with poor health-related quality of life, including sleep impairment.

OBJECTIVE

To assess the extent of sleep impairment, the effect of adalimumab on sleep and other patient-reported outcomes, and correlations between changes in these outcomes and sleep quality in patients with psoriasis.

METHODS

Patients in the 16-week, open-label, Phase IIIb PROGRESS trial had chronic plaque psoriasis and suboptimal response to prior therapy (etanercept, methotrexate or narrowband ultraviolet B phototherapy). Adalimumab was self-injected subcutaneously (80 mg at week 0, then 40 mg every other week from week 1). The focus for this analysis was the Medical Outcomes Study Sleep Scale. Other patient-reported outcomes included the Dermatology Life Quality Index (DLQI), Psoriasis Area and Severity Index (PASI), Physician's Global Assessment, a visual analogue scale for psoriasis/psoriatic arthritis (PsA) pain, and the Work Productivity and Activity Index Questionnaire-Specific Health Problems.

RESULTS

Patients with psoriasis had impaired sleep at baseline. The degree of sleep impairment was significantly associated with the extent of work productivity for all sleep measures and, for some sleep measures, was associated with DLQI impairment, clinical severity measured by PASI, the presence of PsA, and depression. Adalimumab treatment significantly improved sleep quality by 15% from baseline, as well as DLQI score, pain and work productivity. The improvement in sleep was partially explained (R(2 ) = 0·16, P < 0·001) by improvements in the objectively measured psoriasis signs in PASI.

CONCLUSIONS

Adalimumab treatment improved sleep outcomes and other patient-reported outcomes including health-related quality of life, work productivity, daily activity and disease-related pain.

Comparison of medical costs among patients using adalimumab and infliximab: a retrospective study (COMPAIRS)

BACKGROUND

Anti-tumor necrosis factor (TNF) medications have similar efficacy in Crohn's disease (CD), but have not been compared in the real world. This study compared health costs and utilization for patients with CD newly initiating anti-TNF therapy with adalimumab (ADA) or infliximab (IFX) by using insurance data.

METHODS

CD patients initiating ADA or IFX therapy were identified from the MarketScan database. ADA and IFX groups were matched using a propensity score. The primary endpoint was direct costs of healthcare for the 6 months following initiation. The secondary endpoints compared healthcare utilization between groups.

RESULTS

After propensity matching, characteristics were similar between the ADA (n = 623) and IFX (n = 623) groups. During the 6-month interval following anti-TNF initiation, healthcare costs were significantly lower for ADA compared with IFX. Total healthcare cost was $18,885 for ADA and $24,355 for IFX, a difference in cost of $5,470 (P < 0.0001). CD-related costs made up the majority of the costs: $16,454 for ADA and $22,316 for IFX (P < 0.0001). The largest difference in cost was seen in outpatient visits: $2,082 difference between the two groups (P < 0.0001). Both all-cause and CD-related hospitalization decreased for both ADA and IFX groups. Emergency room and hospitalization use in the 6-month follow-up period was not statistically different between groups, although numerically slightly higher in the IFX group.

CONCLUSIONS

Patients with CD using ADA had lower healthcare costs than patients using IFX; this difference was partly driven by outpatient medical costs.

Efficacy and safety of adalimumab among patients with moderate to severe psoriasis with co-morbidities: Subanalysis of results from a randomized, double-blind, placebo-controlled, phase III trial

BACKGROUND

Psoriasis is associated with a variety of major physical and mental co-morbidities.

OBJECTIVE

To assess the incremental burden of co-morbidities on patient-reported outcomes and evaluate the efficacy and safety of adalimumab in psoriasis patients with co-morbidities.

STUDY DESIGN

Data were obtained from the initial 16-week, double-blind treatment period of REVEAL (Randomized controlled EValuation of adalimumab Every other week dosing in moderate to severe psoriasis triAL), a randomized, multicenter, phase III clinical trial.

INTERVENTION

Patients with moderate to severe psoriasis were randomized in a 2 : 1 ratio to receive adalimumab 80 mg (two 40 mg injections administered subcutaneously) at baseline followed by one 40 mg injection every other week from week 1 to week 15 or placebo.

MAIN OUTCOME MEASURES

Clinical severity (Psoriasis Area and Severity Index [PASI]) and patient-reported outcomes (Dermatology Life Quality Index [DLQI], Short Form 36 [SF-36] health survey, Work Productivity and Activity Impairment [WPAI] questionnaire) were assessed during the trial. The effect of selected co-morbidities (i.e. hypertension, psoriatic arthritis, hyperlipidemia, obesity, depression, other forms of arthritis, diabetes mellitus, and other cardiovascular diseases) on patient-reported outcomes was evaluated using multivariate analysis of covariance models. Subgroup analyses were performed by co-morbidity type to statistically compare the clinical efficacy, patient-reported outcome benefits, and safety of adalimumab with placebo in the presence of these conditions.

RESULTS

Study co-morbidities were each independently associated with significantly greater impairment on at least one general patient-reported outcome measured at baseline (all p < 0.05), with the exception of hyperlipidemia. During the 16-week study, adalimumab patients demonstrated significantly greater PASI 75 response rates (defined as a reduction of at least 75% in PASI scores from baseline) compared with placebo patients for all co-morbidity subgroups. Adalimumab provided consistent improvements in DLQI, SF-36 Physical Component Summary and Mental Component Summary scores, and WPAI total scores from baseline to week 16 within co-morbidity subgroups. Rates of serious adverse events (AEs), serious infectious AEs, and AEs leading to discontinuation were comparable between adalimumab and placebo for patients with co-morbidities.

CONCLUSIONS

Co-morbidities were associated with additionally impaired health-related quality of life and work productivity in patients with psoriasis. Adalimumab significantly improved efficacy and patient-reported outcomes and was well tolerated in patients with co-morbidities.

Risk-benefit analysis of adalimumab versus traditional non-biologic therapies for patients with Crohn's disease

BACKGROUND

Adalimumab is indicated for the treatment of moderately to severely active Crohn's disease (CD). A systematic analysis of risks and benefits of adalimumab versus traditional non-biologic therapies for patients refractory to non-biologic therapy is lacking.

METHODS

A base-case analysis compared expected benefits of adalimumab therapy with a 12-week stopping rule for non-responders versus non-biologic therapies using data from clinical trials (CHARM, CLASSIC I). Adverse events (AEs) recorded in clinical trials (CHARM, CLASSIC I, CLASSIC II, GAIN, open-label extensions) were compiled. Sensitivity analyses incorporated all observed benefits of adalimumab and placebo (CHARM, CLASSIC I, GAIN) and observed AEs from a systematic literature review of non-biologic therapies (MEDLINE search of randomized trials 1990-2007). Distributional information from maintenance clinical trial observations and benefit model predictions were used in a probabilistic simulation. Incremental net benefits were estimated based on utility estimates from the literature.

RESULTS

Average time in remission (i.e., CDAI <150) over 1 year of therapy was 39.9% for adalimumab versus 6.6% for traditional non-biologic therapies. Adalimumab was associated with fewer expected hospitalizations, better fistula closure rates, and lower AE rates. These findings were robust in sensitivity analyses. In the probabilistic simulation, with serious AEs as a composite of risks, adalimumab provided greater benefits with fewer AEs versus non-biologic therapies (P < 0.01). Adalimumab demonstrated greater incremental net quality-adjusted life-years (0.12) versus non-biologic therapies.

CONCLUSIONS

Adalimumab demonstrated greater benefits and lower rates of AEs versus traditional non-biologic therapies for patients with moderately to severely active CD who were refractory to non-biologic therapies.

The CHOICE trial: adalimumab demonstrates safety, fistula healing, improved quality of life and increased work productivity in patients with Crohn's disease who failed prior infliximab therapy

BACKGROUND

Adalimumab induces and maintains remission in adults with Crohn's disease.

AIM

To evaluate safety, fistula healing, quality of life and work productivity in adalimumab-treated patients who failed infliximab, including primary nonresponders.

METHODS

After a ≥8-week infliximab washout, patients with moderate-to-severe Crohn's disease received open-label adalimumab as induction (160/80 mg at weeks 0/2) and maintenance (40 mg every other week) therapies. At/after 8 weeks, patients with flare/nonresponse could receive weekly therapy. Minimum study duration was 8 weeks, continuing until the commercial availability of adalimumab for Crohn's disease.

RESULTS

Of 673 patients enrolled, 17% were infliximab primary nonresponders and 83% were initial responders. Three percent of patients had serious infections (mainly abscesses). Complete fistula healing was achieved by 34/88 (39%) patients with baseline fistulas. Improvements in quality of life and work productivity were sustained from week 4 to week 24 for all patients, as well as the subgroup of primary nonresponders.

CONCLUSIONS

Blinded clinical trials have shown adalimumab to be both an effective first-line therapy for anti-TNF-naïve patients and an important treatment option for infliximab-refractory or -intolerant patients. This trial presents open-label experience to support further the safety and effectiveness of adalimumab in patients who failed infliximab therapy, including primary nonresponders (NCT00338650).

Adalimumab sustains clinical remission and overall clinical benefit after 2 years of therapy for Crohn's disease

BACKGROUND

In the randomized, double-blind, placebo-controlled CHARM trial, adalimumab was more effective than placebo in maintaining clinical remission for patients with moderate-to-severe Crohn's disease (CD) through 56 weeks.

AIM

To substantiate the long-term safety and clinical benefits of adalimumab through 2 years of therapy in CHARM and its open-label extension (ADHERE).

METHODS

Patients entering ADHERE on blinded therapy received adalimumab 40 mg every other week (eow). Patients who had already moved to open-label adalimumab eow or weekly in CHARM continued their regimens. Data were analysed by originally randomized treatment group at CHARM baseline (adalimumab 40 mg eow, adalimumab 40 mg weekly, or placebo), regardless of whether patients entered ADHERE or received open-label adalimumab (eow or weekly).

RESULTS

After up to 2 years of therapy, 37.6%, 41.9% and 49.8% of patients originally randomized to placebo, adalimumab eow and adalimumab weekly, respectively, were in clinical remission. All groups experienced sustained improvements on the Inflammatory Bowel Disease Questionnaire. Decreasing hazard rates for both all-cause and CD-related hospitalizations were observed over time. Over a 2-year period, the rates of serious adverse events and malignancies (33.3 and 1.1 events/100-patient-years respectively) were similar to those observed during the overall adalimumab CD clinical development programme.

CONCLUSIONS

Adalimumab demonstrated sustained maintenance of clinical remission, improvements in quality of life and reductions in hospitalization during long-term treatment for CD, with no new safety concerns identified.

Systematic review: the costs of ulcerative colitis in Western countries

BACKGROUND

Early onset and complications such as hospitalization and surgery contribute to the economic burden of ulcerative colitis.

AIM

To review systematically the literature on costs of ulcerative colitis in Western countries.

METHODS

Studies estimating costs of ulcerative colitis in Western countries were identified using Medline, EMBASE and ISI Web of Science and were rated based on relevance and reliability of estimates. All costs were adjusted to 2008 currency values. A parallel review focused on the impact of disease severity on costs, hospitalizations and surgeries.

RESULTS

Estimated annual per-patient direct medical costs of ulcerative colitis ranged from $6217 to $11,477 in the United States and from euro8949 to euro10,395 in Europe. Hospitalizations accounted for 41-55% of direct medical costs. Indirect costs accounted for approximately one-third of total costs in the United States and 54-68% in Europe. Total economic burden of ulcerative colitis was estimated at $8.1-14.9 billion annually in the United States and at euro12.5-29.1 billion in Europe; total direct costs were $3.4-8.6 billion in the United States and euro5.4-12.6 billion in Europe. Direct costs, hospitalizations and surgeries increased with worsening disease severity.

CONCLUSIONS

Ulcerative colitis is a costly disease. Hospitalizations contribute significantly to direct medical costs, and indirect costs are considerable, having previously been substantially underestimated.

High prevalence of potential drug-drug interactions for psoriasis patients prescribed methotrexate or cyclosporine for psoriasis: associated clinical and economic outcomes in real-world practice

BACKGROUND

Methotrexate (MTX) and cyclosporine (CYC) may adversely interact with common medications in patients with psoriasis.

OBJECTIVE

Our purpose was to investigate the prevalence and outcomes of MTX/CYC polypharmacy.

METHODS

We evaluated rates of events that may be associated with drug-related toxicity, health care resource utilization and costs for patients with psoriasis in the Ingenix(R) Impact National Managed Care Database (1999-2007) who were exposed or not exposed to potential drug-drug interactions.

RESULTS

Among 4,583 (57.6%) exposed and 3,372 (42.4%) nonexposed patients, nonsteroidal anti-inflammatory drugs and antibiotics were the most common drugs with potential interactions. The exposed patients had significantly greater risks of developing renal [adjusted odds ratio (OR): 2.58; p = 0.0145], gastrointestinal (OR: 1.36; p = 0.0197) and pulmonary events (OR: 1.20; p = 0.0470), and significantly greater health care resource utilization (e.g. OR for inpatient and emergency department visits: 1.47; p < 0.0001) and costs (adjusted incremental cost: USD 1,722; p < 0.0001).

CONCLUSIONS

MTX/CYC polypharmacy is prevalent in patients with psoriasis and associated with significant risks.

Comparative effectiveness without head-to-head trials: a method for matching-adjusted indirect comparisons applied to psoriasis treatment with adalimumab or etanercept

The absence of head-to-head trials is a common challenge in comparative effectiveness research and health technology assessment. Indirect cross-trial treatment comparisons are possible, but can be biased by cross-trial differences in patient characteristics. Using only published aggregate data, adjustment for such biases may be impossible. Although individual patient data (IPD) would permit adjustment, they are rarely available for all trials. However, many researchers have the opportunity to access IPD for trials of one treatment, a new drug for example, but only aggregate data for trials of comparator treatments. We propose a method that leverages all available data in this setting by adjusting average patient characteristics in trials with IPD to match those reported for trials without IPD. Treatment outcomes, including continuous, categorical and censored time-to-event outcomes, can then be compared across balanced trial populations. The proposed method is illustrated by a comparison of adalimumab and etanercept for the treatment of psoriasis. IPD from trials of adalimumab versus placebo (n = 1025) were re-weighted to match the average baseline characteristics reported for a trial of etanercept versus placebo (n = 330). Re-weighting was based on the estimated propensity of enrolment in the adalimumab versus etanercept trials. Before matching, patients in the adalimumab trials had lower mean age, greater prevalence of psoriatic arthritis, less prior use of systemic treatment or phototherapy, and a smaller mean percentage of body surface area affected than patients in the etanercept trial. After matching, these and all other available baseline characteristics were well balanced across trials. Symptom improvements of ≥75% and ≥90% (as measured by the Psoriasis Area and Severity Index [PASI] score at week 12) were experienced by an additional 17.2% and 14.8% of adalimumab-treated patients compared with the matched etanercept-treated patients (respectively, both p < 0.001). Mean percentage PASI score improvements from baseline were also greater for adalimumab than for etanercept at weeks 4, 8 and 12 (all p < 0.05). Matching adjustment ensured that this indirect comparison was not biased by differences in mean baseline characteristics across trials, supporting the conclusion that adalimumab was associated with significantly greater symptom reduction than etanercept for the treatment of moderate to severe psoriasis.

Impact of adalimumab on symptoms of psoriatic arthritis in patients with moderate to severe psoriasis: a pooled analysis of randomized clinical trials

BACKGROUND

Psoriatic arthritis often affects patients with psoriasis.

OBJECTIVE

To examine the effect of adalimumab on psoriatic arthritis in patients with moderate to severe psoriasis.

METHODS

Data from patients with psoriasis and a reported history of comorbid psoriatic arthritis in 3 randomized, placebo-controlled psoriasis trials of adalimumab were analyzed.

RESULTS

Adalimumab (n = 274) reduced the risk of psoriatic arthropathy adverse events by 75% versus placebo (1.1 vs. 4.8%; p = 0.025). Psoriasis/psoriatic arthritis-related pain was significantly reduced (-31.3 vs. -5.6 visual analog scale units; p < 0.0001). At week 16, adalimumab-treated patients were more likely to respond (56.9 vs. 4.5%; p < 0.001) and responded for a greater percentage of follow-up time (39.3 vs. 2.9%; p< 0.0001) than placebo-treated patients (regression model for PASI 75 and ACR 20 responses).

CONCLUSION

Adalimumab treatment of moderate to severe psoriasis reduced symptoms of comorbid psoriatic arthritis.

Adherence to infliximab maintenance therapy and health care utilization and costs by Crohn's disease patients

INTRODUCTION

Studies suggest infliximab decreases hospitalization and surgery rates in Crohn'fs disease (CD). The aim of this analysis was to evaluate adherence to infliximab maintenance therapy and the impact of medication adherence on health care utilization and costs by patients with CD.

METHODS

Patients with CD who had at least four infliximab infusions (with the time between consecutive infusions < or =12 weeks for the first four infusions) during the first year following infliximab initiation (index date) were identified from the Integrated Health Care Information Service claims database (2002-2006). Nonadherence was defined as fewer than seven infliximab infusions in the first year. One-year health care resource utilization and costs (excluding infliximab drug and administration costs) were compared between adherent and nonadherent patients, with adjustment for baseline characteristics.

RESULTS

A total of 571 patients with CD who were receiving infliximab maintenance therapy were identified. The infusion-based nonadherence rate was 34.3% during the first year of therapy. The multivariate analysis demonstrated that compared with adherent patients, nonadherent patients were more likely to have been hospitalized (odds ratio [OR]=2.7 [all-cause] and OR=2.5 [CD-related]; both P<0.001). Compared with infliximab-adherent patients, adjusted medical costs by nonadherent patients were 73% ($6,692) and 90% ($4,961) greater for all-cause and CD-related medical costs, respectively (both P<0.001), and adjusted hospitalization costs were 115% ($11,450) and 115% ($9,570) greater for all-cause and CD-related hospitalization costs, respectively (both P<0.001).

CONCLUSION

More than one-third of patients on infliximab maintenance therapy were nonadherent to recommended maintenance. Further, nonadherence was associated with increased medical costs and a greater rate of hospitalization.

Economic burden of psoriasis compared to the general population and stratified by disease severity

OBJECTIVE

To evaluate health care utilization and costs for patients with psoriasis vs. the general population and by psoriasis severity.

RESEARCH DESIGN AND METHODS

Claims data were analyzed for adult patients with > or =1 diagnosis of psoriasis and continuous enrollment during the year of 2003 (case sample). A control sample was matched 2:1 on baseline demographic characteristics to the case sample. Case samples were further stratified by psoriasis severity based on treatment patterns. Outcomes were compared descriptively and by a multivariate two-part model to evaluate differences between the case vs. control groups and by psoriasis severity.

MAIN OUTCOME MEASURES

Outcomes included health care resource utilization and health care costs.

RESULTS

A total of 56,528 patients with psoriasis met the inclusion criteria. Patients with psoriasis had significantly greater total health care resource utilization, total medical resource utilization, and total drug utilization vs. the control sample (p < 0.0001). Compared with control patients, patients with psoriasis had significantly greater total health care costs ($5529 vs. $3509), including greater medical costs ($3925 vs. $2687) and drug costs ($1604 vs. $822; all p < 0.0001). Patients with moderate to severe psoriasis (n = 5248) had greater total health care costs vs. patients with mild psoriasis (n = 51,280) ($10,593 vs. $5011), including greater medical costs ($5854 vs. $3728) and drug costs ($4738 vs. $1283; all p < 0.0001). Multivariate analyses confirmed the increased utilization and costs in all comparisons.

LIMITATIONS

The study limitations included limited generalizability of the findings beyond the study population, classification of disease severity based on treatment instead of clinical measures, and exclusion of out-of-pocket costs and indirect costs in the study.

CONCLUSIONS

Patients with psoriasis incur greater health care resource utilization and costs compared with the general population. Psoriasis severity is positively associated with increased health care resource utilization and costs.

Cost utility of adalimumab versus infliximab maintenance therapies in the United States for moderately to severely active Crohn's disease

OBJECTIVE

To determine and compare the cost utilities of the tumour necrosis factor (TNF) antagonists adalimumab and infliximab as maintenance therapies for patients in the US with moderately to severely active Crohn's disease.

METHODS

Maintenance regimens of adalimumab (40 mg every other week) and infliximab (5 mg/kg) were compared using primary data from the CHARM and published data from the ACCENT I clinical trials. Differences in study samples were minimized by matching and weighting baseline characteristics (Crohn's Disease Activity Index score, age and sex) between the patient groups using the primary clinical trial data. Utilization data were estimated from trial data. Unit costs of TNF antagonists (year 2007 values), hospitalizations (year 2006 values), and other medical costs (year 2006 values) were derived from a systematic literature search. Standard gamble-calculated primary data were used to derive health-utility estimates. Data were analysed in a cost-utility framework from a private payer perspective over a 56-week time horizon. Univariate and probabilistic sensitivity analyses were used to explore uncertainty related to the base-case cost-utility analysis. Given the time horizon, costs and effects were not discounted.

RESULTS

Adalimumab- and infliximab-treated patients were in remission for 47.2% and 37.1% of the 56-week period, respectively. Hospital admissions were 34-40% lower for adalimumab than for infliximab, based on the model and observed data, respectively. Patients treated with adalimumab accrued greater expected QALYs (0.014; 95% CI 0.000, 0.022) and lower costs (-$US4852; 95% CI -6758, 491) in the first year of therapy than patients treated with infliximab. Compared with infliximab maintenance therapy, adalimumab had lower drug and administration costs, less drug waste, and lower hospitalization rates. Univariate and multivariate probabilistic sensitivity analyses suggested that these results were robust.

CONCLUSIONS

This analysis suggests that adalimumab maintenance therapy is a dominant strategy versus infliximab maintenance therapy for patients with moderate to severe Crohn's disease. Adalimumab appeared more effective and less costly than infliximab.

Loss of treatment response to infliximab maintenance therapy in Crohn's disease: a payor perspective

OBJECTIVES

To assess the incidence and economic implications of loss of treatment response among patients with Crohn's disease (CD) treated with infliximab maintenance therapy.

METHODS

This was a retrospective observational study of infliximab response and costs among patients with CD using a large health-care claims database. Patients with CD receiving infliximab maintenance therapy with an initial response were selected from the Integrated Healthcare Information Services claims database (1999-2005). Patients' claim histories were used to identify patterns of response to infliximab treatment. Incidence of loss of response was estimated using Kaplan-Meier method. Annual total health-care and CD-related costs were estimated and adjusted for inflation to 2005 US dollars. Generalized linear model was used to assess the impact of loss of response on treatment costs.

RESULTS

The study sample included 262 patients with CD with an initial response to infliximab therapy. Within 24 months of therapy initiation, 77% of patients lost treatment response. Upward dose adjustment, a new drug therapy for CD, and CD-related emergency room or inpatient visits were the three most common indicators of loss of response. Both annual total and CD-related health-care costs for patients who lost treatment response during the first year were found to be approximately one-third higher than for those who did not lose response.

CONCLUSIONS

The majority of patients who had initial responses to infliximab maintenance treatment subsequently lost response within 2 years. Loss of response was associated with a significant increase in total health-care and CD-related costs.

The costs of Crohn's disease in the United States and other Western countries: a systematic review

OBJECTIVE

To conduct a critical and systematic literature review of the costs of Crohn's disease (CD) in Western industrialized countries.

RESEARCH DESIGN AND METHODS

Studies published in English that described the cost of CD in Western industrialized countries were identified using three major databases (Medline, EMBASE, and ISI Web of Science). Studies were reviewed and rated based on their relevance to cost of illness and the reliability of the estimates. All costs were adjusted for inflation to 2006 values.

RESULTS

Estimated direct medical costs were $18,022-18,932 per patient with CD per year in the United States, and euro 2898-6960 in other Western countries. Hospitalizations accounted for 53-66% of direct medical costs, with an average cost-per-hospitalization of $37,459 in the United States. Estimated indirect costs accounted for 28% of the total cost in the United States and 64-69% in Europe. Costs differed greatly by disease severity. Costs of patients with severe disease were 3- to 9-fold higher than patients in remission. Direct medical costs in the United States for patients in the top 25% of total costs averaged $60,582 per year; costs of patients in the top 2% averaged more than $300,000 per year. Combining prevalence rates, the total economic burden of CD was $10.9-15.5 billion in the United States and euro 2.1-16.7 billion in Europe.

LIMITATIONS

This review is limited by the research quality and variations of the individual studies reviewed, and only includes English articles.

CONCLUSIONS

This updated literature synthesis demonstrated the substantial total cost burden of CD, of which hospitalizations accounted for more than half of direct medical costs.

Quality of life findings from a multicenter, multinational, observational study of patients with metastatic hormone-refractory prostate cancer

BACKGROUND

The assessment of health-related quality of life (HRQL) for patients with hormone-refractory prostate cancer (HRPC) is of paramount importance because new treatments have a modest impact on survival but side effects of treatment and disease symptoms can significantly impact HRQL.

METHODS

This was an observational, non-interventional, multi-center, multi-national cohort study of patients with metastatic HRPC. Health-related quality of life was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C30), the Functional Assessment of Cancer Therapy-Prostate (FACT-P) and the EQ-5D index. Mean changes from baseline to month 3, 6, and 9 were computed and tested using paired t-tests.

RESULTS

FACT-P PCS, EQ-5D index and 10 of 14 EORTC domains were statistically significantly lower (P < 0.05) than the baseline scores at the 3, 6 and 9 month visits. The domains that did not reach statistical significance were cognitive functioning, insomnia, diarrhea and financial difficulties.

CONCLUSIONS

These data demonstrate that patients with metastatic HRPC experience rapid, significant deterioration in HRQL, highlighting the need for effective palliative therapy for men with HRPC.

Quality of life as a potential predictor for morbidity and mortality in patients with metastatic hormone-refractory prostate cancer

BACKGROUND

The association between HRQL measures with outcomes in patients with metastatic hormone-refractory prostate cancer (HRPC) is unclear.

METHODS

Baseline and 12-week HRQL was collected using the European Organization for Research and Treatment of Cancer (EORTC QLQ-C30) and the Functional Assessment of Cancer Therapy - Prostate (FACT-P). Outcomes included: (1) survival; (2) time to disease progression and (3) time to bone pain. Cox proportional hazards regression models were used. The relative predictive performance of each HRQL instrument and domain was compared.

RESULTS

Baseline HRQL scores and 12-week change scores > the median were significant predictors of all clinical outcomes but varied by domain. For example, the hazard of death for a change in FACT-P Grand Total Score > median was 49% of the hazard for a change < or = the median. Including baseline or 12-week change in HRQL resulted in improvement in prediction performance.

CONCLUSIONS

Patients with better baseline HRQL have better predicted survival, time to disease progression and pain prognosis than those with worse HRQL. In addition, the 12-week change in HRQL appears to improve predictive accuracy for most clinical outcomes. It appears that greater deterioration in HRQL is prognostic for rapid disease progression.