Background/Purpose: The treatment of RA has changed dramatically in the past several decades with the advent of a large number of new biologic agents as well as trials that have shown the benefits of optimizing the use of conventional disease modifying agents (DMARDs) alone or in combinations. It is not clear how the large number of clinical trials and treatment recommendations related to these issues have influenced RA management. This analysis considers two aspects of DMARD choice and delivery for RA: 1) use of biologic agents as initial DMARD treatment; and 2) use of subcutaneously (SC) administered methotrexate (MTX) in patients who cannot be managed with oral drug. To evaluate trends, these questions were addressed in two patient cohorts, one that started treatment in 2009 and a second that initiated therapy in 2012.

Methods:  The analysis used Symphony Health Solutions’ anonymized patient-level claims data which captures ~274 million US patients and 92% of all prescription drugs dispensed in the United States. The analysis included RA patients identified by ICD-9 codes 714.0 and 714.30 who initiated treatment with oral MTX or a biologic in 2009 or 2012 and were then followed through to 2014. Treatment in the year prior to these treatments was also evaluated. This analysis focused on patients who had a biologic agent as their initial DMARD in 2009 or 2012 and those in whom SC MTX was employed after initiation of therapy with oral drug.

Results: The study included 48,910 patients who started oral MTX or biologic treatment in 2009 and 107,536 who initiated such treatment in 2012. In the 2009 cohort, 13,270 patients (27.1%) initiated treatment with a biologic vs 38,209 (35.6%) in the 2012 cohort (p<0.0001). This difference did not appear to result from differences between groups in baseline demographic or clinical characteristics (Table). A higher percentage of patients in the 2012 cohort received a non-MTX DMARD in the year prior to biologic initiation vs the 2009 cohort (25.4% vs 15.3%, p<0.0001), but even when these patients are excluded from the analysis, the higher initial use of a biologic in the 2012 remained significant (p<0.0001). There was also significantly increased employment of SC MTX in the 2012 cohort. 35,640 patients in the 2009 cohort initiated oral MTX and 20,041 (56.2%) switched away from this treatment over 5 years. Of these, 2,513 (12.5%) were switched to SC MTX. 69,327 patients in the 2012 cohort started oral MTX and 18,989 (27.4%) switched away from this treatment over 2 years. Of these, 3,976 (20.9%) switched to SC MTX (p<0.0001 vs the 2009 cohort).

Conclusion:  This analysis indicated three significant trends in the treatment of RA in the US: 1) increasing use of non-MTX DMARDs prior to the initiation of a biologic; 2) increasing use of a biologic without prior administration of any conventional DMARD; and 3) increasing, but not optimal, employment of SC MTX after use of oral MTX.  

« Back to 2016 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/rheumatoid-arthritis-ra-premature-use-of-biologics-accelerating-in-united-states-us/