Treatment Persistence and Healthcare Costs Among Patients with Rheumatoid Arthritis Changing Biologics in the USA

Abstract

IntroductionAfter a patient with rheumatoid arthritis (RA) fails tumor necrosis factor inhibitor (TNFi) treatment, clinical guidelines support either cycling to another TNFi or switching to a different mechanism of action (MOA), but payers often require TNFi cycling before they reimburse switching MOA. This study examined treatment persistence, cost, and cost per persistent patient among MOA switchers versus TNFi cyclers.MethodsThis study of Commercial and Medicare Advantage claims data from the Optum Research Database included patients with RA and at least one claim for a TNFi (adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab) between January 2012 and September 2015 who changed to another TNFi or a different MOA therapy (abatacept, tocilizumab, or tofacitinib) within 1 year. The index date was the date of the change in therapy. Treatment persistence was defined as no subsequent switch or 60-day gap in therapy for 1 year post-index. RA-related costs included plan-paid and patient-paid amounts for inpatient, outpatient, and pharmacy claims. Medication costs included index and post-index costs of TNFi and different MOA therapies.ResultsThere were 581 (38.3%) MOA switchers and 935 (61.7%) TNFi cyclers. The treatment persistence rate was significantly higher for MOA switchers versus TNFi cyclers (47.7% versus 40.2%, P = 0.004). Mean 1-year healthcare costs were significantly lower among MOA switchers versus TNFi cyclers for total RA-related costs ($37,804 versus $42,116; P < 0.001) and medication costs ($29,001 versus $34,917; P < 0.001). When costs were divided by treatment persistence, costs per persistent patient were lower among MOA switchers versus TNFi cyclers: $25,436 lower total RA-related cost and $25,999 lower medication costs.ConclusionMOA switching is associated with higher treatment persistence and lower healthcare costs than TNFi cycling. Reimbursement policies that require patients to cycle TNFi before switching MOA may result in suboptimal outcomes for both patients and payers.FundingSanofi and Regeneron Pharmaceuticals.

Impact of Plan-Level Access Restrictions on Effectiveness of Biologics Among Patients with Rheumatoid or Psoriatic Arthritis

“…Previous use of a tumor necrosis factor inhibitor (TNFi) is a negative predictor of effectiveness with an alternate TNFi, but there is currently a lack of evidence on the impact of previous TNFi use on the subsequent effectiveness of bDMARDs with a different mechanism of action [30]. The impact of disease duration on response to treatment has been mixed [32][33][34], but is likely confounded by the negative impact of TNFi cycling on both adherence and effectiveness [35,36]. Neither prior use of a TNFi specifically nor disease duration were examined in relation to bDMARD treatment patterns in this study.…”

Defining response to TNF-inhibitors in rheumatoid arthritis: the negative impact of anti-TNF cycling and the need for a personalized medicine approach to identify primary non-responders

“…Currently, there is no way to determine which RA patients will respond to a targeted treatment. In clinical practice, it is common for non-responding patients to cycle among several anti-TNFs prior to switching to a drug with a different mechanism of action (MOA) [61]. There is a clear unmet need for a PM approach to predict response to anti-TNF therapies before treatment initiation to avoid harming patients, especially those who respond partially or not at all to therapy and continue to try various treatments while their disease progresses [4].…”

“…Hence, long-term treatment is not recommended for patients who do not respond to therapy [6]. Yet, it is common practice for primary non-responders to anti-TNF drugs to receive multiple anti-TNFs for prolonged periods, often years [61].…”

“…Other studies [23,24,25] reported switching from an anti-TNF medication to the anti-CD20 therapy, rituximab (Rituxan), was associated with better clinical outcomes than switching to another anti-TNF therapy. Furthermore, switching to a treatment with AATT is more effective than cycling to another anti-TNF in patients with an inadequate response to the initial anti-TNF drug [27,61]. Together, these data demonstrate that switching to AATT therapy after anti-TNF treatment failure improves clinical outcomes for patients with RA [26,60,68] and is more efficient in terms of healthcare In studies 36 and 39 rituximab was prescribed as the only alternative mechanism of action, in study 38 the medication used was one of the AATTs in Table 4 prescribed by the rheumatologist costs and medication compliance [61] than TNF-cycling.…”

“…Furthermore, switching to a treatment with AATT is more effective than cycling to another anti-TNF in patients with an inadequate response to the initial anti-TNF drug [27,61]. Together, these data demonstrate that switching to AATT therapy after anti-TNF treatment failure improves clinical outcomes for patients with RA [26,60,68] and is more efficient in terms of healthcare In studies 36 and 39 rituximab was prescribed as the only alternative mechanism of action, in study 38 the medication used was one of the AATTs in Table 4 prescribed by the rheumatologist costs and medication compliance [61] than TNF-cycling. This is supported by ACR and EULAR guidelines, which recommend AATTs as an option to an anti-TNF as a first-line therapy, or as a second-line therapy after one anti-TNF has been tried, instead of switching to a second anti-TNF [61].…”