Kim Gilwan, Barner Jamie C, Rascati Karen, Richards Kristin
Health Outcomes and Pharmacy Practice Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.
Health Outcomes and Pharmacy Practice Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.
Clin Ther. 2016 Mar;38(3):646-54. doi: 10.1016/j.clinthera.2016.01.022. Epub 2016 Feb 18.
Little is known about the transition from nonbiologic disease-modifying antirheumatic drugs (DMARDs) to biologic DMARDs or about individual nonbiologic DMARD use patterns among patients with rheumatoid arthritis (RA). This study examined time to initiation of biologic DMARDs and nonbiologic DMARD medication adherence and persistence among Texas Medicaid recipients with RA taking nonbiologic DMARDs.
In this retrospective study (July 1, 2003-December 31, 2010) of the Texas Medicaid database, patients were aged 18 to 62 years at index, were diagnosed with RA (International Classification of Diseases, Ninth Revision, Clinical Modification, code 714.xx), had no claims for nonbiologic or biologic DMARDs in the preindex period, and had a minimum of 2 prescription claims for the same nonbiologic DMARD in the postindex period. Kaplan-Meier survival analysis and log-rank tests were used to compare time to initiation of biologic DMARDs according to nonbiologic DMARD type and therapy. Adherence and persistence were examined according to nonbiologic type and therapy by using ANOVA models and χ(2), Duncan, and t tests.
On average, patients were 47.9 (± 10.4) years of age, mostly female (89.1%) and Hispanic (55.2%). Methotrexate (MTX) and leflunomide (LEF) users took the shortest time to initiate biologic DMARDs (207 [190] days and 188 [205] days, respectively). LEF users had the highest mean adherence of 37.5% (27.5%), which was similar to MTX users (35.7% [26.9%]), whereas dual-therapy users had the lowest mean adherence at 17.1% (14.4%). Sulfasalazine users (108 [121] days) had the lowest persistence, whereas LEF (227 [231] days) and MTX (211 [222] days) users had the longest persistence. Nonbiologic DMARD monotherapy users were more adherent than dual-therapy users (32.6% [25.8%] vs 17.1% [14.4%]).
These results should be interpreted in light of some study limitations, such as using proportion of days covered as a proxy for adherence, not having clinical data to control for RA severity, and lack of generalizability to all US populations. Given the study findings, both clinicians and other decision makers may want to investigate the potential driving factors of initiation of biologic DMARDs to provide effective RA management and consider patient education programs to enhance medication adherence and persistence to RA medications.
对于类风湿关节炎（RA）患者从非生物性改善病情抗风湿药（DMARDs）转换为生物性DMARDs的情况，以及个体非生物性DMARD的使用模式，人们了解甚少。本研究调查了德克萨斯州医疗补助计划中正在服用非生物性DMARDs的RA患者开始使用生物性DMARDs的时间，以及非生物性DMARD的用药依从性和持续性。
在这项对德克萨斯州医疗补助数据库的回顾性研究（2003年7月1日至2010年12月31日）中，患者在索引日期时年龄为18至62岁，被诊断为RA（国际疾病分类第九版临床修订本，代码714.xx），在索引日期前没有非生物性或生物性DMARDs的索赔记录，并且在索引日期后至少有2次相同非生物性DMARD的处方索赔记录。采用Kaplan-Meier生存分析和对数秩检验，根据非生物性DMARD的类型和治疗方法比较开始使用生物性DMARDs的时间。通过方差分析模型以及χ²检验、邓肯检验和t检验，根据非生物性DMARD的类型和治疗方法来检查依从性和持续性。
患者平均年龄为47.9（±10.4）岁，大多数为女性（89.1%）和西班牙裔（55.2%）。甲氨蝶呤（MTX）和来氟米特（LEF）使用者开始使用生物性DMARDs的时间最短（分别为207 [190]天和188 [205]天）。LEF使用者的平均依从性最高，为37.5%（27.5%），与MTX使用者（35.7% [26.9%]）相似，而联合治疗使用者的平均依从性最低，为17.1%（14.4%）。柳氮磺胺吡啶使用者（108 [121]天）的持续性最低，而LEF（227 [231]天）和MTX（211 [222]天）使用者的持续性最长。非生物性DMARD单药治疗使用者比联合治疗使用者更依从（32.6% [25.8%]对17.1% [14.4%]）。
这些结果应结合一些研究局限性来解释，例如使用覆盖天数比例作为依从性的替代指标，没有临床数据来控制RA的严重程度，以及缺乏对所有美国人群的普遍性。鉴于研究结果，临床医生和其他决策者可能需要调查开始使用生物性DMARDs的潜在驱动因素，以提供有效的RA管理，并考虑开展患者教育项目，以提高对RA药物的用药依从性和持续性。
