Persistence and dose escalation of tumor necrosis factor inhibitors in US veterans with rheumatoid arthritis

Grant W Cannon; Scott L DuVall; Candace L Haroldsen; Liron Caplan; Jeffrey R Curtis; Kaleb Michaud; Ted R Mikuls; Andreas Reimold; David H Collier; David J Harrison; George J Joseph; Brian C Sauer

doi:10.3899/jrheum.140164

Persistence and dose escalation of tumor necrosis factor inhibitors in US veterans with rheumatoid arthritis

J Rheumatol. 2014 Oct;41(10):1935-43. doi: 10.3899/jrheum.140164. Epub 2014 Aug 15.

Affiliations

¹ From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc. Grant.Cannon@va.gov.
² From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc.

PMID: 25128516
DOI: 10.3899/jrheum.140164

Abstract

Objective: Limited evidence exists comparing the persistence, effectiveness, and costs of biologic therapies for rheumatoid arthritis in clinical practice. Comparative effectiveness studies are needed to understand real-world experience with these agents. We evaluated treatment patterns, costs, and effectiveness of tumor necrosis factor inhibitor (TNFi) agents in patients enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry.

Methods: Observational data from the VARA registry and linked administrative databases were analyzed. Longitudinal data from VARA patients initiating adalimumab (ADA), etanercept (ETN), or infliximab (IFX) from 2003 (the date all agents were available within the Veteran Affairs) to 2010 were analyzed. Outcomes included Disease Activity Score using 28 joints (DAS28), treatment persistence, dose escalation, and direct costs of drugs and drug administration.

Results: For 563 eligible patients, baseline DAS28, DAS28 improvements, and persistence on initial treatment were similar across agents. Fewer patients receiving ETN (n = 5/290; 2%) underwent dose escalation than did patients taking ADA (n = 32/204; 16%) or IFX (n = 44/69; 64%). Annual costs for first course of TNFi therapy were lower for injectable ADA ($13,100 US) and ETN ($13,500 US) than for intravenously administered IFX ($16,900 US).

Conclusion: Despite similar persistence and clinical disease activity for these TNFi agents, rates of dose escalation were highest with ADA and IFX. Higher overall costs were noted for IFX without increases in effectiveness.

Keywords: ADALIMUMAB; ETANERCEPT; INFLIXIMAB; RHEUMATOID ARTHRITIS.

Publication types

Observational Study
Research Support, Non-U.S. Gov't

MeSH terms

Adalimumab / administration & dosage
Adalimumab / therapeutic use*
Aged
Antirheumatic Agents / administration & dosage
Antirheumatic Agents / therapeutic use*
Arthritis, Rheumatoid / drug therapy*
Databases, Factual
Dose-Response Relationship, Drug
Etanercept / administration & dosage
Etanercept / therapeutic use*
Female
Humans
Infliximab / administration & dosage
Infliximab / therapeutic use*
Male
Middle Aged
Registries
Treatment Outcome
Tumor Necrosis Factor-alpha / antagonists & inhibitors*
Veterans*

Substances

Antirheumatic Agents
Tumor Necrosis Factor-alpha
Infliximab
Adalimumab
Etanercept