Background/Purpose: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that affects multiple organs including the heart, lungs, kidneys, joints, and the nervous system. Standard therapies for SLE include corticosteroids, antimalarial agents, non-steroidal anti-inflammatory drugs, cytotoxic agents, and immunosuppressive/immunodulatory agents, some of which can be associated with significant toxicity. The objective of this study is to describe how SLE treatment evolves over time in newly diagnosed SLE patients in the U.S.

Methods: This retrospective, observational cohort study (HO-13-13054) followed incident SLE patients’ treatment for 5 years in the Truven commercial and Medicaid claims database. The earliest date of a medical claim with a diagnosis of SLE (710.0x) from Jan 1, 2004 to Dec 31, 2009 was defined as the index date. Patients were required to be ≥ 18 years old at index date, had continuous medical and pharmacy benefits for 24 months prior to index date without SLE diagnosis and 12 months after index date with ≥ 1 SLE-related inpatient claim or ≥ 2 office or emergency room visits with an SLE diagnosis at least 30 days apart. At least one SLE diagnosis on or during 12 months after index date must be made by a rheumatologist, dermatologist, nephrologist, or neurologist.

Results: 4,036 commercially insured incident SLE patients (mean age: 46.9 years; female: 88.8%; mean Charlson comorbidity index (CCI): 1.01; mean follow up: 1,289 (SD: 645) days) and 234 incident patients with Medicaid coverage (mean age: 42.5 years; female: 94.0%; mean CCI: 1.80; mean follow up: 1,389 (SD: 767) days; white: 18.4%, black: 59.4%, Hispanic 1.3%, other: 20.9%) were identified. The number of patients in both cohorts declined over time due to insurance change or death. The proportion of patients with ≥ 1 prescriptions of SLE therapies decreased over 5 years after diagnosis (Table). In the first year after diagnosis, corticosteroid treatment rate was 48.1% and 62.8%, antimalarial treatment rate was 53.4% and 57.3%, and immune suppressive treatment rate was 22.2% and 25.6% in commercially insured and Medicaid insured patients, respectively. Biologic use in the two cohorts was no more than 1.5% throughout the period.

Table: Proportion of Patients with SLE Treatment Over Time in Commercially Insured and Medicaid Incident SLE Patients

	% with ≥ 1 prescriptions, commercially insured SLE patients (%)					% with ≥ 1 prescriptions, Medicaid SLE patients (%)
Year after SLE diagnosis	1 N=4,036	2 N=4,029	3 N=3,149	4 N=2,144	5 N=1,311	1 N=234	2 N=234	3 N=161	4 N=120	5 N=98
Corticosteroids	48.1	35.3	26.4	22.3	19.2	62.8	44.4	31.1	27.5	20.4
Antimalarials	53.4	42.9	31.7	26.0	22.0	57.3	39.3	29.8	20.0	19.4
Immune suppressives	22.2	19.2	13.9	11.7	10.5	25.6	21.4	17.4	12.5	12.2
Anti-TNFs (including adalimumab, certolizumab, etanercept, golimumab and infliximab)	1.5	1.5	1.2	1.0	0.9	0.4	0.0	0.0	0.0	0.0
Other Biologics (including abatacept, tocilizumab and rituximab)	0.0	0.2	0.1	0.1	0.0	0.0	0.0	0.0	0.0	0.0

Conclusion: Over a 5 year period, SLE patients were treated with less antimalarials, immune suppressive regimens, and targeted therapies than reported in tertiary lupus cohorts. This could reflect poor adherence, inability to afford medication, milder disease, or practitioner unfamiliarity with prescribing agents other than corticosteroids. The decrease in prescriptions over time might relate to response to treatment, lapses in physician or patient education, or exit of more severe patients from the cohorts. Further study is needed to explore the implications of treatment options upon outcomes.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/continuous-variables-of-treatment-interventions-in-patients-diagnosed-with-systemic-lupus-erythematosus-among-commercially-and-medicaid-insured-populations-in-the-u-s/