Medication Choices and Medication Survival in a National Multicentre Community Based Rheumatoid Arthritis Cohort

Lynden Roberts¹, Kathleen Tymms², Julien P. de Jager³, Geoffrey O. Littlejohn⁴, Hedley Griffiths⁵, Dave Nicholls⁶, Paul Bird⁷, Julie Hill⁸, Philip McCloud⁸, James C. Scott⁹, Jane Zochling¹⁰ and OPAL Consortium¹¹, ¹School of Medicine, James Cook University, Townsville, Australia, ²Canberra Rheumatology, Canberra, ACT, Australia, ³Suite 2, Osler House, Southport, Australia, ⁴Rheumatology, Monash Medical Center, Melbourne, Australia, ⁵Barwon Rheumatology Service, Geelong, Australia, ⁶Coast Joint Care, Maroochydore, Australia, ⁷Combined Rheumatology Practice, Sydney, Australia, ⁸Statistics, McCloud Consulting Group, Sydney, Australia, ⁹Medical Affairs, Roche Products Pty Limited, Sydney, Australia, ¹⁰Menzies Research Institute Tasmania, Hobart, Australia, ¹¹Melbourne, Australia

Meeting: ACR/ARHP Annual Meeting 2012

Keywords: DMARDs and rheumatoid arthritis (RA)

Session Information

Title: Rheumatoid Arthritis - Clinical Aspects I: Drug Studies/Drug Safety/Drug Utilization/Disease Activity & Remission

Session Type: Abstract Submissions (ACR)

Background/Purpose: A sizeable body of high-quality research underpins our knowledge of the efficacy of various RA therapies. Outside the controlled environment of these clinical trials, however, in real world practice many additional factors may influence the use of DMARD/bDMARDs. There is little knowledge of whether the trial evidence is being implemented in real world settings, or whether the trial efficacy and safety translates into clinical effectiveness.

Methods: Point of care clinical software has been used to collect data since 2009 from 20 participating Australian rheumatology treatment centres. Patients with a rheumatologist diagnosis of RA were identified. Medication changes were analysed in 9 prespecified categories to permit the construction of population treatment algorithms. Medication survival was assessed using Kaplan Meier plots. The change in disease activity following a medication change was also assessed.

Results: RA patients numbered 9570, with 73% female, mean age 62, and median disease duration 7 years. Any DMARD was used in 87% overall, and 30% had used a biologic DMARD. The DMARDbDMARD usage above 1% in the cohort included methotrexate 71%, Hydroxychloroquine 25%, Leflunomide 24%, Sulfasalazine 17%, Etanercept 12%, Adalimumab 11%, Tocilizumab 5%, Abatacept 3%, Golimumab 3%, Rituximab 2.5%, and Certolizumab 2%. Median DMARD survival ranged from 49 to 231 months for the most common DMARDs and from 9 to 49 months for the most common biologic DMARDs. A tree diagram representing the observed treatment changes was constructed. Of the 2256 patients whose first RA medication was monotherapy Methotrexate and who required a change, 31% changed to greater than 1 conventional DMARD, 29% added Leflunomide, 17% added a bDMARD, and 16% ceased therapy. Of the 466 patients whose first change in RA medication was to Methotrexate plus Leflunomide and required a second change, 31% returned to monotherapy Methotrexate, 18% changed or added another conventional DMARD, 20% changed to monotherapy DMARD other than methotrexate, and 28% added a bDMARD.

Conclusion: Australian rheumatologists are making frequent changes in medications in their RA patients and appear to be implementing best evidence guidelines. Australian regulatory requirements for utilizing subsidised biologic therapy may also be affecting choices. The most commonly observed treatment algorithm in patients who required therapeutic escalation had patients starting with DMARD monotherapy followed by DMARD combination therapy followed by bDMARD combined with DMARD combination therapy. Shorter median survival of biologic therapies than traditional therapies may reflect the more refractory nature of the patients who are selected for these therapies. Analysis of the effect of a medication switch on disease activity will be of interest in this cohort.

Disclosure:

L. Roberts,
None;

K. Tymms,
None;

J. P. de Jager,
None;

G. O. Littlejohn,
None;

H. Griffiths,
None;

D. Nicholls,
None;

P. Bird,
None;

J. Hill,
None;

P. McCloud,
None;

J. C. Scott,

Roche Pharmaceuticals,

J. Zochling,
None;

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