RA Deaths, Hospitalizations, Surgeries Reduced by Biologics?

Alice Goodman

November 19, 2012

WASHINGTON, DC — Tumor necrosis factor (TNF) inhibitor therapy is linked to a reduced need for hospitalizations and surgery in people with rheumatoid arthritis (RA), an Irish study has shown. The reduced need for hip and knee replacement surgery led to an overall cost savings of more than $21 million.

In addition, a Canadian study has shown that biologics appear to reduce the risk for premature death.

Both studies were presented here at ACR 2012.

To better understand how the use of TNF inhibitors has affected hospitalization and surgery rates, Irish researchers from St. Vincent's University Hospital in Dublin looked at the number of hospital inpatient days and musculoskeletal surgical procedures in RA patients treated with TNF inhibitors. In 2010, TNF inhibitors cost US$130 million in Ireland.

"These data suggest that TNF prescribing is one of the factors that has led to reductions in inpatient days and surgical procedures. Other factors may have also improved outcomes, including increased numbers of rheumatology consultants, shorter waiting times to see patients, the ability to use methotrexate, and the ability to treat to targets.... The data are nonetheless compelling; the advent of the biologic era has improved health-related outcomes in patients with RA," said senior study author Oliver M. FitzGerald, MD, from the Department of Rheumatology at St. Vincent's Hospital.

Fewer Hospitalizations and Joint Replacements in the Biologic Era

Dr. FitzGerald explained that in the prebiologic era, an estimated one third of RA patients experienced deterioration in joint function severe enough to require joint replacement surgery during their lifetime. "Studies around the world suggest that the incidence of these procedures is reduced in the biologic era," he said.

The researchers reviewed data from 57 hospitals on patients admitted from 1995 to 2012 with a diagnosis of RA using the national Hospital Inpatient Enquiry System database. The team analyzed the records of 57,774 RA patients; two thirds were female and the mean age was 66 years.

They found that TNF inhibitor prescriptions increased 156% each year from 2000 to 2010 (from 2389 to 116,747 units), and that this increase in prescriptions coincided with a 13% reduction per year in inpatient admissions for RA patients (from 49,000 per year before 2002 to 31,000 in 2010; P = .0055).

Musculoskeletal surgical procedures in the Irish cohort decreased from about 500 per year to just under 200 in recent years — a 47% decrease. Hip replacement surgery was reduced by 47%, and total knee replacement surgery by 53%.

Reduced Risk for Death

The Canadian study found an association between the use of biologic agents and a 25% reduction in the risk for premature mortality (P < .0001). The study was based on Ministry of Health data from patients with RA treated from January 1996 to March 2006; they were followed until March 2010. The 2156 patients treated with biologics were matched with control subjects for age, sex, and calendar year; control subjects were biologic-naïve but had been treated with at least 3 other disease-modifying drugs. The number of deaths reported in the biologic group was 247 and in the control group was 326.

"Since people with RA are at increased risk of dying prematurely, knowing that the medications used to treat the disease reduce this risk is meaningful.... Specifically, the study will help people weigh the risks and benefits when they are deciding which medications to take to treat the disease," said lead author Diane Lacaille, MD, associate professor at the Arthritis Research Center of Canada, University of British Columbia, Vancouver.

"Short-Sighted" to Consider Only Direct Drug Costs

"There is no doubt that tight control of RA reduces hospitalizations and surgeries. If...a year of biologics costs $28,000, you need to take into account that this saves more than hospitalization costs. It doesn't take many days in the hospital to reach the cost of the drug. It is short-sighted to just think of the direct drug cost," said Eric Ruderman, MD, from the Northwestern University Feinberg School of Medicine in Chicago, Illinois, who was not involved in either study.

Methotrexate can achieve disease control in about one third of RA patients, he continued. The other 65% are candidates for biologics. "We need to find the sweet spot and use biologics when they are appropriate," he said.

Dr. FitzGerald reports financial ties with Abbott Immunology Pharmaceuticals and Bristol-Myers Squibb. Dr. Lacaille has disclosed no relevant financial relationships. Dr. Ruderman reports receiving research grants from Pfizer and Celgene; and receiving consultant fees from Amgen, Genentech, Lilly, Vertex, and Janssen.

ACR 2012: Abstract 2540, presented November 13, 2012; Abstract 1642, presented November 12, 2012.