DMARD-Naive PsA Patients Switch Soon After First Scrip

Kate Johnson

June 14, 2012

June 14, 2012 (Berlin, Germany) — Less than a quarter of psoriatic arthritis (PsA) patients initiating first-time treatment with nonbiologic disease-modifying antirheumatic drugs (DMARDs) remain on the index drug for a year. In addition, 77% switch at least once during the year, usually in the first 3 months, according to research reported here at the European League Against Rheumatism Congress 2012.

"A significant proportion switched to or augmented with a biologic DMARD shortly after initiation of the first oral DMARD," said Frank Zhang, MD, from Celgene Corporation in Summit, New Jersey.

The results were a surprise to the 2 European rheumatologists who chaired the session in which the study was presented.

Josef S. Smolen, MD, professor of internal medicine and chair of the Department of Rheumatology at the Vienna General Hospital, University of Vienna, in Austria, wondered why American rheumatologists "swap therapies within 3 months, long before the peak maximum effect can be seen."

"It did seem to be a very high proportion to change that soon; it's not something we see in our practice," said the other moderator, Laura Coates, MD, PhD, a researcher at the University of Leeds in the United Kingdom.

The researchers analyzed data on 1786 PsA patients from a US MarketScan Commercial Claims database (2005 to 2009) who had received at least 2 diagnoses of PsA from a physician and were new users of DMARDs.

Treatment patterns were captured for 1 year after the first DMARD prescription (index date).

Treatment discontinuation was defined as a treatment gap of at least 60 consecutive days, and the initiation of a new oral DMARD was categorized as either a switch (when the index medication was stopped) or an augmentation of the index medication.

For the majority of patients (72%), the index drug was methotrexate; for 17%, it was sulfasalazine, said Dr. Zhang.

Within a median of 82.5 days, 77% of the patients had made some kind of treatment change, with 42% of them starting a biologic agent.

Of those who modified their treatment, 75% discontinued the index drug and 25% augmented it. Of those who discontinued their treatment, 30% switched to another drug (56% to biologics, 23% to oral corticosteroids, and 21% to nonbiologic DMARDs), Dr. Zhang said.

Although there are recommendations for progression of PsA treatments, little is known about treatment patterns in "a real-world setting," Dr. Zhang explained.

"These results give us a better understanding of the factors related to treatment changes and better inform us about unmet needs in PsA patients," he concluded.

Although surprised by the findings, Dr. Coates said the lack of depth of the data makes it hard to speculate on. "We don't know why they switched.... We don't know if they switched because they couldn't tolerate the drug, or maybe they wanted to have children," she said, pointing out that about one third of patients who start methotrexate discontinue because of intolerance.

Insurance company or national health services rules that stipulate that people must have a certain amount of time on a standard DMARD before they can move on to a biologic might be affecting this pattern, she said. "If patients are required to have a 3-month trial with a nonbiologic, you could try that for 3 months and then switch them quite quickly. In the United Kingdom, patients have to fail 2 DMARDs, with a minimum 3-month trial of each. Unless you put people on 2 drugs together at the beginning, then it requires that we do a 6-month trial with standard DMARDs."

The findings are not surprising to Kenneth Saag, MD, director of the Center for Education and Research on Therapeutics of Musculoskeletal Disorders, director of the Center for Outcomes, Effectiveness Research and Education, and Jane Knight Lowe Professor of Medicine in the division of clinical immunology and rheumatology at the University of Alabama, Birmingham.

He told Medscape Medical News that the "switching of biologics in the United States is motivated by many factors, including the constantly changing reimbursement policies of the healthcare payers and, in the special case of psoriatic arthritis management, the involvement of multiple physicians in the treatment."

Dr. Zhang is an employee of Celgene Corporation, which funded the study. Dr. Coates has disclosed no relevant financial relationships. Dr. Saag reports receiving research support from Amgen, Merck, and Novartis; and being a consultant for Amgen, Eli Lilly, and Merck.

European League Against Rheumatism (EULAR) Congress 2012: Abstract OP0159. Presented June 8, 2012.

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