Background/Purpose: JAK inhibitors (JAKi) are targeted synthetic DMARDs (tsDMARDs) with a different mode of action (MOA) to conventional synthetic and biologic DMARDs (cs and bDMARDs). In Australia the cost of b/tsDMARDs for treatment of RA is subsidized if the patient has high levels of clinical/laboratory disease activity and has not responded to a pre-specified combination of csDMARDs, including methotrexate. Once eligible for subsidy the clinician can prescribe the b/tsDMARD deemed most clinically appropriate until the desired level of disease control has been reached. The aim of this analysis was to determine the patterns of use and reasons for initiation and discontinuation of JAKi in real-world 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 consultation. Data from RA patients 18 years and older who commenced a b/tsDMARD between Jan-2007 and Mar-2020 were 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 47,455 patients with RA in the data set; 27% prescribed b/tsDMARDs. Of patients on treatment at Mar 2020, 51% were receiving a TNF inhibitor (TNFi) and 23% a JAK inhibitor (JAKi), with the remainder receiving tocilizumab, abatacept or rituximab. Of patients who commenced their treatment after JAKi’s become available in Sept 2015, 45% were treated with a TNFi, and 32% were treated with a JAKi. Tofacitinib (TOF) has been the most prescribed b/tsDMARD since Sept 2015 with 21% of all initiations; however, since baricitinib (BARI) became available in Sept 2018, it has taken over as the preferred JAKi with 23% of new initiations compared to 14% for TOF. From Sept 2018-Mar 2020 etanercept and adalimumab were the most commonly prescribed first line agents, followed by BARI then TOF; however, BARI was the most prescribed agent in lines 2-6+. The main clinician-listed reason for choice of TOF was MOA in 58%, efficacy compared with alternatives in 21%, mode of administration in 11%, efficacy as monotherapy in 7%, and safety in 1%. BARI was chosen for MOA in 28%, efficacy compared with alternatives in 42%, mode of administration in 19%, efficacy as monotherapy in 8%, and safety in 1%. The main reasons for stopping TOF were lack of efficacy (34%), better alternative (25%), and adverse reaction (14%); those for BARI were lack of efficacy (35%), adverse reaction (25%), and better alternative (12%). Patient non-adherence was listed in 1% and 2% of cessations for TOF and BARI, respectively. 49% of patients discontinuing a JAKi in first line switched to a TNFi in second line, and 34% switched to another JAKi, citing lack of efficacy, adverse reaction, and better alternative as the reason for switching.

Conclusion: There has been significant and sustained uptake of JAKi for the management of RA in Australia. MOA and perceived efficacy rate much higher than mode of administration for clinicians when selecting a JAKi. Clinical outcomes and persistence following JAKi cycling requires further investigation.

« Back to ACR Convergence 2020

ACR Meeting Abstracts - https://acrabstracts.org/abstract/uptake-of-janus-kinase-inhibitors-for-management-of-rheumatoid-arthritis-in-australia/