Background/Purpose:  Biologic therapies have become a standard of care for many pediatric rheumatic diseases such as juvenile idiopathic arthritis (JIA) and periodic fever syndromes.  Biologics, including adalimumab, etanercept, canakinumab, and tocilizumab, are categorized as specialty medications. Specialty medications are generally defined by the following: use in the treatment of complex chronic conditions, high cost (typically >$600 per month), usually requiring special storage, handling, and site-of-care administration, and involving a significant degree of patient education, monitoring, and management. Barriers that can prevent patients from obtaining specialty medications include need for prior authorizations, high copayments, directing prescriptions to the preferred specialty pharmacies, and coordinating delivery of medications from the specialty pharmacy. Pharmacists can be used in the ambulatory setting to aid in procurement and management of specialty medications. Nationwide Children’s Hospital (NCH) has instituted a specialty pharmacy for the division of rheumatology to aid in prior authorization, injection teaching, and medication management of select biologic therapies. This is expected to result in increased adherence to treatment and achievement of inactive disease. The primary aim of this pilot study is to assess the medication possession ratio (MPR) for individuals on adalimumab, etanercept, canakinumab, and tocilizumab that were enrolled in NCH Specialty Pharmacy for an index period of October 2016 to January 2017.

Methods:  A retrospective review of prescriptions filled at NCH Specialty Pharmacy over a 4 month period assessed overall number of prescriptions, number of specialty prescriptions, patients enrolled, and MPR for adalimumab, etanercept, canakinumab, and tocilizumab. MPR was calculated for patients with >1 fills at NCH Specialty Pharmacy. An MPR of 1 reflects 100% adherence.

Results:  In the first four months, NCH Specialty Pharmacy filled a total of 446 prescriptions and 132 specialty medications (adalimumab n=55; etanercept n=37; canakinumab n=19; tocilizumab n=11; other n=10) for 46 rheumatology patients. Average and median MPRs were assessed for adalimumab (0.95, 1) etanercept (0.95, 1), canakinumab (0.99, 1), and tocilizumab (1, 1), respectively. Overall, the average MPR was 0.96 and median MPR was 1.

Conclusion:   The implementation of an institutional specialty pharmacy has added services to improve outcomes for children with rheumatic diseases. NCH was able to ensure a median MPR of 1 for all biologics filled at NCH Specialty Pharmacy during the pilot phase. It is expected that improvement in medication adherence will result in achievement of inactive disease. Strategies used by NCH Specialty Pharmacy to maintain an MPR of 1 include coordination of prior authorization, injection teaching by a pharmacist, and medication management consisting of monthly follow up with the patient or caregiver to schedule medication delivery. Rheumatologists at NCH will continue to enroll patients with JIA and other autoinflammatory diseases in NCH Specialty Pharmacy to ensure streamlined care and improved patient outcomes.