Background European and US guidelines recommend MTX as part of initial treatment for patients with RA.1,2 Biologic agents are recommended for patients with poor prognostic indicators and those who fail to achieve treatment goals after 3–6 months of conventional therapy.1,2 Currently, it is not clear how closely these recommendations are being followed in the US.
Objectives To assess patterns of treatment for patients who initiated DMARD treatment in the US in either 2009 or 2012 and were followed for at least 2 years.
Methods The analysis used Symphony Health Solutions' anonymized patient-level claims data which captures ∼274 million US patients. Analysis included RA patients identified by ICD-9 codes 714.0 and 714.30 who initiated treatment with either oral MTX or a biologic therapy in 2009 or in 2012 and were followed for 2 years. Information obtained included: demographic characteristics, initial treatments, switches from oral to subcutaneous (SC) MTX and/or biologics (with or without concomitant MTX), timing of treatment changes, and oral MTX or SC MTX dosing at the times of switches/additions or end of follow-up.
Results The study included 48,910 patients who initiated treatment in 2009 and 107,636 who started treatment in 2012 (Table). For the RA patients who started treatment in 2009, 27.1% initiated therapy with a biologic and 72.9% started on oral MTX. The respective values for patients initiating therapy in 2012 were 35.6% and 64.4%. Over the first 2 years of follow-up, 35.2% of patients who started MTX in 2009 and 21.6% of those started on MTX in 2012 switched to a biologic or had one added to MTX. A small percentage of patients in each cohort switched from oral to SC MTX. The median duration of oral MTX treatment prior to switching to or adding a biologic was 60 days for patients who initiated treatment in 2009 and 177 days for those who initiated MTX in 2012.
Conclusions In the US, a large percentage of RA patients receive a biologic without a prior trial of MTX and this approach to treatment increased from 2009 to 2012. While there is a trend toward underuse of MTX as initial treatment from 2009 to 2012, a higher percentage of patients who started MTX in 2012 remained on this treatment for at least 2 years vs those started in 2009. This suggests many clinicians may not be following best practice with regard to the use of SC MTX.
Smolen JS, Landewe R, Breedveld FC, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis. 2014;73:492–509.
Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol. 2016;68:1–26.
Acknowledgement Study sponsored by Medac Pharma, Inc.
Disclosure of Interest J. O'Dell: None declared, S. Cohen Grant/research support from: Abbvie, Amgen, Astellas, Medac, Pfizer, UCB, C. Thorne Grant/research support from: Abbive, Amgen, Celgene, CaREBiodam, Lilly, Novartis, Pfizer, Sanofi, UCB, Consultant for: Abbvie, Centocor, Genzyme, Hospira, Medexus, Pfizer, Paid instructor for: Abbvie, Centocor, Genzyme, Hospira, Medexus/Medac, Pfizer, T. Mikuls Grant/research support from: Roche/Genentech, Consultant for: Pfizer