Background/Purpose:
It is unclear how recommendations for disease modifying anti-rheumatic drugs (DMARDs) & biological agents in treatment of Rheumatoid Arthritis (RA) have influenced their use over the past decade. Using the department of Veterans Affairs (VA) as a model to represent a large multi-facility health care organization, we studied the trend of MTX dosing and the use of traditional DMARD/biologics in treating Veterans with RA over a 10-year period from 2000 to 2009.

Methods:
Using various national administrative databases of the department of VA, we found an incident cohort of 13,254 RA patients with validated algorithms to identify RA. Descriptive statistics were used to characterize trends in MTX start and highest dose and changes in patterns of DMARDs and biologics usage over the study period.

Results:
Use of biologics increased from 2.8% in 2000-2001 to 18.9% in 2008-2009. Between 2000 and 2001, etanercept was the main biologic available, and it represented 96.2% of all biologics used. Since the introduction of adalimumab in 2003, its use increased tremendously, and by 2008-2009, it became the most used biological agent for the treatment of RA in our study population (48.5%). For the first DMARD/biologic used in a DMARD-naïve RA patient, there was an increase in use of MTX over time from 39.8% to 52.1%. There was also a gradual decline in both hydroxychloroquine and sulfasalazine as first line agents. Use of biologics as first-line agents remained relatively unchanged over the study period at 1.3-3.6 %. For the subjects who had been on MTX monotherapy for 90 or more days (52.9% of 13,254), between 2001-2002 and 2008-2009, the mean MTX start dose increased slightly but significantly from 10.1 to 11.4mg per week (p<0.01) and the proportion who were started on MTX less than 10mg per week dropped from 43.2% to 22.1% (p<0.01). Over the same time period, the mean maximum MTX dose attained increased significantly from 15.6 to 17.8 mg per week  (p<0.01) and the proportion attaining peak dose of MTX of less than 15mg/week dropped from 35.0% to 17.0% (p<0.01).

Conclusion:
The use of DMARDs and biologics in treatment of RA has changed markedly over the past decade. The increased use of MTX as the first line agent is consistent with it becoming the anchor drug for RA treatment. Though the start and maximum MTX dose attained have increased significantly over the decade, the average maximum dose at the end of our study is still considered low compared with current standards. Biologics have been gaining acceptance and now play an important role in RA treatment. In the VA system, adalimumab has become the most common biologic used in 2008-2009.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/10-year-trends-in-the-use-of-disease-modifying-anti-rheumatic-drugs-dmards-and-biologic-agents-in-rheumatoid-arthritis-a-national-veteran-affairs-study/