Bonafede Machaon M K, McMorrow Donna, Proudfoot Clare, Shinde Shraddha, Kuznik Andreas, Chen Chieh-I
Senior Director of Outcomes Research, Truven Health Analytics, an IBM Company, Cambridge, MA.
Lead Analyst, Truven Health Analytics, an IBM Company.
Am Health Drug Benefits. 2018 Jun;11(4):192-202.
Targeted disease-modifying antirheumatic drug (DMARD) options for rheumatoid arthritis (RA) include tumor necrosis factor (TNF) inhibitors (adalimumab, certolizumab, etanercept, golimumab, infliximab) or alternative mechanisms of action (MOAs), such as a T-cell co-stimulation modulator (abatacept), Janus kinase inhibitor (tofacitinib), or interleukin-6 inhibitor (tocilizumab).
To examine treatment persistence and healthcare costs in patients with RA who changed therapy by cycling therapy (ie, switching within the same drug class), or switching between, the TNF inhibitors and alternative MOA medication classes.
We analyzed medical and pharmacy claims for commercially insured patients who cycled or switched between targeted DMARD agents between January 1, 2010, and September 30, 2014 (ie, the index date), to determine treatment patterns (ie, treatment switching, discontinuation, restarting after a gap ≥60 days, or persistence) and costs (plan- and patient-paid) for 1 year postindex. The cost per persistent patient was the total healthcare cost divided by the number of treatment-persistent patients.
The analysis included 6203 patients who cycled between TNF inhibitors, 2640 patients who switched from TNF inhibitors to alternative MOA agents, 699 patients who cycled between alternative MOA agents, and 687 patients who switched from alternative MOA agents to TNF inhibitors. The 1-year treatment persistence rates (with values vs TNF inhibitor cyclers) were 45.2% for TNF inhibitor cyclers, 50.3% for TNF inhibitor-alternative MOA switchers ( <.001), 51.4% for alternative MOA agent cyclers ( = .002), and 46.1% for alternative MOA-TNF inhibitor switchers ( = .63). Compared with TNF inhibitor cyclers, the cost per persistent patient was lower for TNF inhibitor-alternative MOA switchers (-$16,853 RA-related; -$19,280 targeted DMARDs), alternative MOA agent cyclers (-$21,662 RA-related; -$25,153 targeted DMARDs), and alternative MOA-TNF inhibitor cyclers (-$7206 RA-related; -$7919 targeted DMARDs).
Among patients with RA, patients who switched from a TNF inhibitor to an alternative MOA agent and those who cycled between alternative MOA agents had significantly higher treatment persistence rates and a substantially lower cost per persistent patient than those who cycled between TNF inhibitors. These findings support the evaluation of switching medication classes for patients with RA when a targeted therapy fails.
类风湿关节炎（RA）的靶向改善病情抗风湿药（DMARD）选择包括肿瘤坏死因子（TNF）抑制剂（阿达木单抗、赛妥珠单抗、依那西普、戈利木单抗、英夫利昔单抗）或其他作用机制（MOA），如T细胞共刺激调节剂（阿巴西普）、Janus激酶抑制剂（托法替布）或白细胞介素-6抑制剂（托珠单抗）。
研究通过循环治疗（即在同一药物类别内换药）或在TNF抑制剂与其他MOA药物类别之间换药的RA患者的治疗持续性和医疗费用。
我们分析了2010年1月1日至2014年9月30日（即索引日期）期间在靶向DMARD药物之间循环或换药的商业保险患者的医疗和药房理赔数据，以确定索引日期后1年的治疗模式（即治疗换药、停药、间隔≥60天后重新开始或持续治疗）和费用（计划支付和患者自付）。每位持续治疗患者支付的费用为总医疗费用除以治疗持续患者的数量。
分析包括6203例在TNF抑制剂之间循环的患者、2640例从TNF抑制剂换用其他MOA药物的患者、699例在其他MOA药物之间循环的患者以及687例从其他MOA药物换用TNF抑制剂的患者。1年治疗持续率（与TNF抑制剂循环者相比），TNF抑制剂循环者为45.2%，TNF抑制剂-其他MOA换药者为50.3%（P<0.001），其他MOA药物循环者为51.4%（P = 0.002），其他MOA-TNF抑制剂换药者为46.1%（P = 0.63）。与TNF抑制剂循环者相比，TNF抑制剂-其他MOA换药者每位持续治疗患者的费用更低（与RA相关的费用低16,853美元；靶向DMARD费用低19,280美元），其他MOA药物循环者（与RA相关的费用低21,662美元；靶向DMARD费用低25,153美元），以及其他MOA-TNF抑制剂循环者（与RA相关的费用低7206美元；靶向DMARD费用低7919美元）。
在RA患者中，从TNF抑制剂换用其他MOA药物的患者以及在其他MOA药物之间循环的患者，其治疗持续率显著高于在TNF抑制剂之间循环的患者，且每位持续治疗患者的费用大幅降低。这些发现支持在靶向治疗失败时对RA患者换药类别的评估。
