Background/Purpose: In Australia the cost of biologic/targeted synthetic DMARDs (b/tsDMARDs) for treatment of PsA is subsidized if the patient has documented high levels of clinical/laboratory disease activity and has not responded to a pre-specified combination of conventional synthetic DMARDs, including methotrexate. Once eligible for subsidy the clinician can then prescribe the b/tsDMARD deemed most clinically appropriate until the desired level of disease control is reached, with the available options being adalimumab, etanercept, certolizumab pegol, golimumab, infliximab, secukinumab, ixekizumab, ustekinumab and tofacitinib. The aim of this analysis was to determine the patterns of use and reasons for initiation and discontinuation of b/tsDMARDs for PsA in real-world rheumatology practice in Australia.

Methods: Deidentified clinical data were sourced from the OPAL dataset, which is collected in a custom-built electronic medical record at the time of the consultation¹ by 110 rheumatologists in Australia. Prescribing data for patients >18 years with PsA treated with a b/tsDMARD between Jan 2007-Mar 2020 was included in the analysis. The software program Tableau^® was used to display data on medication initiation and cessation dates, and reasons for starting and stopping b/tsDMARDs, which is recorded at the time of the decision.

Results: At Mar 2020, there were 13,767 PsA patients in the dataset, with 35% (4,854) prescribed b/ts DMARDs. 67% of patients were receiving a TNF inhibitor (TNFi), 22% an IL-17 inhibitor (IL-17i), 7% a JAK inhibitor (JAKi) and 4% an IL-12/IL-23 inhibitor. In the prior 12 months (April 2019-Mar 2020) TNFi was the preferred 1^st line treatment (66%) with adalimumab taking 31% of all initiations, followed by secukinumab and golimumab (16% of initiations each). Secukinumab was the most prescribed bDMARD in 2^nd line (23%) followed by tofacitinib (21%), and tofacitinib was the most prescribed 3^rd line agent (31%) followed by secukinumab (20%). Mode of action (MOA) was selected as the most common reason for choosing a drug (48%), followed by efficacy compared to alternatives (34%) and efficacy as monotherapy (11%). Mode of administration was considered the driver for 17% of tofacitinib initiations compared to 5% overall. The main reasons for stopping treatment were lack of efficacy (40%), better alternative (25%) and adverse reaction (12%). 42% of patients who switched from a TNFi in 1^st line received a TNFi in 2^nd line, 33% switched to an IL-17i, and 23% switched to a JAKi. 43% of patients that switched from an IL-17i switched to a TNFi, 33% switched to a JAKi, and 24% switched to an alternative IL-17i.

Conclusion: Clinicians appraise different characteristics of each drug when choosing interventions for their patients. MOA is rated highly which is reflected in the rapid uptake of IL-17i and JAKi in early lines of therapy for patients with PsA. Clinical outcomes following in-class switching versus switching to an agent with a different MOA requires further investigation.

References: ¹ Littlejohn GO, Tymms KE, Smith T, Griffiths HT. Using big data from real-world Australian rheumatology encounters to enhance clinical care and research. Clin Exp Rheum Nov 2019.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/changing-patterns-of-use-of-biologic-targeted-synthetic-dmards-in-psoriatic-arthritis-an-analysis-of-the-opal-dataset/