Background/Purpose: Use of biologic agents for the treatment of rheumatoid arthritis continues to grow rapidly, with the cost of these agents putting a significant strain on health care budgets.  Although rheumatologists and third party payers share the goal of ensuring quality of care for RA patients, rheumatologists fear potential limitation of access to biologics due to cost while third party payers are concerned about the rising expenses associated with the use of these agents.  Treatment pathways have been suggested as a tool to address these issues.

Methods: Seventy nine rheumatologists from 35 practices in the mid-Atlantic region participated in a payer-sponsored, rheumatologist-developed RA treatment clinical pathway.  To be considered compliant with the pathway, practices were required to enter all RA patients insured by the payer, utilize oral DMARDs for at least 3 months prior to use of a biologic agent, prescribe the biologic agent at the lowest approved dose, and increase dose according to package guidelines.  Initial biologic therapy could include any of the TNF, abatacept (SC or IV) or tocilizumab (SC or IV).    Rituximab or tofacitinib were reserved for previous biologic failures.  Patients were not required to change biologics for ongoing disease activity, but biologics could not be initiated, switched or increased in dose if the patient was in Clinical Disease Activity Index (CDAI) remission.   Persistence and mean CDAI were calculated and evaluated at 6 and 12 months for patients on TNF and non-TNF agents.

 Results: From 1/1/12 to 12/31/2013, Of 3200 patients on the pathway, 586 patients started a new biologic(s) in the study period, 137 started their first biologic and 449 switched to another biologic.  301 patients were analyzed at treatment initiation based on their CDAI score availability of which 159 initiated TNF agents and 142 initiated non TNF- agents.   Of these patients, 65% were persistent on therapy at 6 months on TNF agents and 84% on non-TNF agents; at 12 months, 52% were persistent on TNF agents and 65% on non-TNF agents.  The mean CDAI scores at 6 months  were 7.7 for TNF group versus 10.2 for non-TNF group (p=.010); while at 12 months the mean CDAI scores were 8.6 in TNF and 10.7 in non-TNF group respectively although the difference  was not statistically significant as assessed by t-test (p=.23).  Overall the mean CDAI score for patients who initiated a biologic was 12.6, while the mean CDAI score for patients who persisted on their biologic for a year was 9.7.   

Conclusion: Persistence decreased over time in both TNF and non-TNF patients with higher rate of drop off occurring in patients on TNF. Patients exhibit improvement in CDAI scores, while participating in the Pathway program.  Guideline-driven care is taking into consideration both efficacy and costs and has no negative impact on patient reported outcomes.

« Back to 2015 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/evaluation-of-persistence-and-outcomes-in-patients-treated-with-tnf-and-non-tnf-biologics-following-treatment-clinical-pathway-in-rheumatoid-arthritis/