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Extended report
Inequity in biological DMARD prescription for spondyloarthritis across the globe: results from the ASAS-COMOSPA study
  1. Elena Nikiphorou1,2,
  2. Désirée van der Heijde1,
  3. Sam Norton2,
  4. Robert BM Landewé3,
  5. Anna Molto4,
  6. Maxime Dougados4,
  7. Filip E Van den Bosch5,6,
  8. Sofia Ramiro1
    1. 1 Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
    2. 2 Academic Rheumatology Department, King’s College London, London, UK
    3. 3 Department of Clinical Immunology and Rheumatology, Amsterdam Rheumatology Center, Amsterdam, The Netherlands and Zuyderland Medical Center, Heerlen, The Netherlands
    4. 4 Department of Rheumatology, Paris Descartes University, Department of Rheumatology - Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, INSERM (U1153): Clinical epidemiology and biostatistics, PRES Sorbonne Paris-Cité, Paris, France
    5. 5 VIB Inflammation Research Center, Ghent University, Ghent, Belgium
    6. 6 Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
    1. Correspondence to Dr Elena Nikiphorou, Academic Rheumatology Department, King’s College London, Weston Education, Denmark Hill, SE1 1UL, UK; enikiphorou{at}


    Objectives The value of biological disease-modifying antirheumatic drugs (bDMARDs) in spondyloarthritis (SpA) is well recognised, but global access to these treatments can be limited due to high costs and other factors. This study explores country variation in the use of bDMARDs in SpA in relation to country-level socioeconomic factors.

    Methods Patients fulfilling the Assessment in SpondyloArthritis International Society (ASAS) SpA criteria in the multinational, cross-sectional ASAS Comorbidities in Spondyloarthritis study were studied. Current use of bDMARDs or conventional synthetic DMARDs (csDMARDs) was investigated in separate models, with multilevel logistic regression analysis, taking the country level into account. Contribution of socioeconomic factors, including country health expenditures, gross domestic product and human development index as independent country-level factors, was explored individually, in models adjusted for sociodemographic as well as clinical variables.

    Results In total, 3370 patients from 22 countries were included (mean (SD) age 43 (14) years; 66% male; 88% axial disease). Across countries, 1275 (38%) patients were bDMARD users. Crude mean bDMARD use varied between 5% (China) to 74% (Belgium). After adjustment for relevant sociodemographic and clinical variables, important variation in bDMARD use across countries remained (P<0.001). Country-level socioeconomic factors, specifically higher health expenditures, were related to higher bDMARD uptake, though not meeting statistical significance (OR 1.96; 95% CI 0.94 to 4.10). csDMARD uptake was significantly lower in countries with higher health expenditures (OR 0.32; 95% CI 0.15 to 0.65). Similar trends were seen with the other socioeconomic variables.

    Conclusions There remains important residual variation across countries in bDMARD uptake of patients with SpA followed in specialised SpA centres. This is independent of well-known factors for bDMARD use such as clinical and country-level socioeconomic factors.

    • spondyloarthritis
    • dmards (biologic)
    • dmards (synthetic)

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    • Handling editor Josef S Smolen

    • Twitter @ElenaNikiUK

    • Contributors EN wrote a first draft of the manuscript, which was then reviewed and edited by SR, RBML, DvdH and SN. AM, MD, FEvdB and SN provided advice and support on the statistical analyses, and all coauthors contributed to further revisions of the manuscript and confirmed approval prior to final submission.

    • Funding The COMOSPA study was conducted with the financial support of Abbvie, Pfizer and UCB, who provided an unrestricted grant to ASAS to fund the study.

    • Disclaimer The funders did not have any role in the design or conduct of the study. This ancillary study did not receive any funding, and the sponsors of COMOSPA did not have any interference with this current study.

    • Ethics approval The study was conducted according to guidelines for good clinical practice in all countries with all local ethics committees approving the ASAS-COMOSPA study protocol.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Collaborators Fadoua Allali MD, Morocco; Raquel Almodovar Gonzàlez MD, Spain; Elena Alonso Blanco-Morales MD, Spain; Alejandro Alvarellos MD, Argentina; Maria Aparicio Espinar MD, Spain; Pamir Atagunduz MD, Turkey; Pauline Bakker MD, Netherlands; Juan C. Barreira MD. Argentina; Leila Benbrahim MD, Morocco; Bahia Benchekroun MD, Morocco; Alberto Berman MD, Argentina; Juergen Braun MD, Germany; Alain Cantagrel MD PhD, France; Roberto Caporali MD, Italy; Pedro Carvalho MD, Portugal; Gustavo Casado MD, Argentina; James Cheng-Chung Wei MD, PhD, Tawian; Francisco Colombres MD, Argentina; Eugenio del Miguel Mendieta MD PhD, Spain; Juan D. Diaz-Garcia MD, Mexico; Michel De Bandt MD PhD, France; Vanesa Duarte MD, Argentina; Cristina Fernandez Carballido MD, Spain; Mari Cruz Fernandez Espartero MD, Spain; Manuel Fernandez-Prada MD, Spain; Rene-Marc Flipo MD PhD, France; Pilar Font Ugalde MD. PhD, Spain; Philippe Gaudin MD PhD, France; Philippe Goupille MD, France; Dolors Grados Cànovas MD, Spain; Jordi Gratacós Masmitjà MD PhD, Spain; Vittorio Grosso MD, ITALY; Naomi Ichikawa, MD Japan; Hisashi Inoue MD, Japan; Yuko Kaneko MD PhD, Japan; Taku Kawasaki MD PhD, Japan; Shigeto Kobayashi MD, Japan; Manjari Lahiri MD, Singapore; Hernàn Maldonado-Ficco MD, Argentina; Marhadour MD, France; Alejandro Martínez MD, Argentina; Kazuo Matsui MD, Japan; Ramón Mazzuchelli Esteban MD, Spain; Corinne Micelli MD PhD, France; Chisun Min MD, Japan; Mitsuhiro Morita MD PhD, Japan; Juan Mulero Mendoza MD PhD, Spain; Jose Raul Noguera Pons MD, Spain; Masato Okada MD, Japan; Alberto Ortiz MD, Argentina; Jon Packham DM FRCP, UK; Gisela Pendón MD, Argentina; Dora Pereira MD, Argentina; José A Pereira da Silva MD, Portugal; Fernando Pimentel-Santos MD, Portugal; Hanan Rkain, MD MOROCCO; Oscar Rillo MD, Argentina; Carlos Rodriguez Lozano MD, Spain; Adeline Ruyssen-Witrand MD PhD, France; Adriàn Salas MD, Argentina; Carlos Salinas-Ramos MD, Mexico; Amelia Santosa MD, Singapore; Alain Saraux MD PhD, France; Raj Sengupta FRCP PGCME, UK; Stefan Siebert PhD, UK; Martin Soubrier MD PhD CHU, France; Caroline Spiegel, Germany; Carmen Stolwijk MD, Netherlands; Kurisu Tada MD, Japan; Naoho Takizawa MD, Japan; Yoshinori Taniguchi MD PhD, Japan; Atsuo Taniguchi MD PhD, Japan; Chung Tei Chou MD, Taiwan; Lay-Keng Teoh Singapore; Tetsuya Tomita MD PhD, Japan; Wen-Chan Tsai MD, PhD, Taiwan; Shigeyoshi Tsuji MD PhD, Japan; Olga Tsyplenkova, Germany; Astrid van Tubergen MD PhD, Netherlands; Kiana Vakil-Gilani BS, MPH, USA; Rafael Valle-Oňate MD, Colombia; Gaelle Varkas MD, Belgium; Virginia Villaverde MD, Spain; Ai Yap Singapore; Pedro Zarco Montejo MD PhD, Spain.