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The American Journal of Managed Care Special Issue: Pharmacy Benefits
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Disease-Modifying Antirheumatic Drug Initiation Among Patients Newly Diagnosed With Rheumatoid Arthritis
Machaon Bonafede, PhD, MPH; Barbara H. Johnson, MBA; Neel Shah, PhD, BPharm; David J. Harrison, PhD; Derek Tang, PhD, BSPharm; and Bradley S. Stolshek, PharmD
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Two-Year Adherence and Costs for Biologic Therapy for Rheumatoid Arthritis
Bradley S. Stolshek, PharmD; Sally Wade, MPH; Alex Mutebi, PhD, MSc; Ajita P. De, MA, MPhil, MS; Rolin L. Wade, MS; and Jason Yeaw, MPH
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Two-Year Adherence and Costs for Biologic Therapy for Rheumatoid Arthritis

Bradley S. Stolshek, PharmD; Sally Wade, MPH; Alex Mutebi, PhD, MSc; Ajita P. De, MA, MPhil, MS; Rolin L. Wade, MS; and Jason Yeaw, MPH
Adherence to newly initiated biologic therapy for rheumatoid arthritis is important for long-term adherence.

Objectives: To evaluate adherence to newly initiated biologic disease-modifying antirheumatic drugs (bDMARDs) in effectively treated patients with rheumatoid arthritis (RA).

Study Design: Retrospective cohort study of administrative claims data (IMS PharMetrics Plus) for services incurred from July 1, 2008, to December 31, 2014.

Methods: Data from patients with RA aged 18 to 64 years with continuous enrollment for at least 30 months and initiating abatacept, adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab were analyzed. Treatment effectiveness was determined using a validated algorithm. Outcomes included adherence rates (proportion of days covered ≥80%) for 1 year and 2 years, year 2 adherence among patients effectively and noneffectively treated in year 1, year 2 adherence predictors, and year 2 costs and cost predictors.

Results: Across 10,374 patients, adherence rates were 46% for year 1 and 34% for 2 years; rates were lowest for golimumab and highest for infliximab. In year 1, 3076 (29.7%) patients were considered effectively treated. Year 2 adherence was 59% in effectively treated patients, 32% in patients who failed any effectiveness criteria, and 12% in patients who failed only the adherence criterion. Intravenous bDMARDs, older age, male sex, Northeast region, commercial payer, prior DMARD use, index year 2010 or later, and lower preindex all-cause costs each predicted better adherence. Adjusted year 2 all-cause and RA-related costs were $39,425 and $22,123, respectively, for effectively treated patients and $25,313 and $9250 for noneffectively treated patients. Cost predictors included effective treatment, region, payer, and index year.

Conclusions: Adherence to the first bDMARD was suboptimal even in effectively treated patients, suggesting opportunities to improve adherence in patients with RA initiating biologics.

Am J Manag Care. 2018;24(Spec Issue No. 8):SP315-SP321
Takeaway Points
  • Compared with noneffectively treated patients, patients who were effectively treated in the first year of biologic therapy for rheumatoid arthritis (RA) were more likely to be adherent in the second year of therapy.
  • Adherence was suboptimal in both effectively and noneffectively treated patients, indicating a need for better strategies to improve adherence in patients with RA initiating biologic therapy.
Rheumatoid arthritis (RA) is a chronic disease that requires long-term therapy. The goal of treatment is to achieve low disease activity or remission and to inhibit the progression of joint damage and other complications from RA.1 American College of Rheumatology guidelines suggest multiple options to assess disease activity, including the Disease Activity Score based on 28 joints (DAS 28).2 An algorithm to determine effective treatment based on DAS 28 outcomes from claims databases has been developed and validated.3 A key component of the algorithm is adherence (ie, taking medication in accordance with prescribed timing and dose), and this approach is intended to ensure that the patient’s disease activity is attributable to the initial medication rather than to subsequent therapies.3

Currently available therapies for moderate to severe RA include conventional synthetic disease-modifying antirheumatic drugs (csDMARDs; eg, methotrexate) and biologic DMARDS (bDMARDs).1 The most commonly used bDMARDs include the selective T-cell costimulation modulator abatacept and the tumor necrosis factor inhibitors adalimumab, certolizumab pegol, etanercept, golimumab, and infliximab.

Understanding medication use, particularly adherence and persistence (ie, medication use without significant gaps in therapy), is important in achieving clinical goals. In particular, although the short-term and long-term utilization patterns for bDMARDs directly influence treatment effectiveness, utilization over the longer term is not well understood. In general, real-world adherence to bDMARDs, as evaluated by medication utilization in claims data in patients with RA, is suboptimal, although most studies have not examined periods longer than 12 months.4 Poor adherence to all RA medications has been associated with disease progression or flares5,6 and increased healthcare resource utilization.7-9

These findings of studies on adherence and outcomes reflect the experience of heterogeneous RA populations, which suggests that maintaining adherence is likely important even for patients with low disease activity who have met criteria for being effectively treated. Treatment adherence following periods when patients were effectively or noneffectively treated have not yet been described for patients in the routine care setting. Therefore, in this study, we assessed adherence and persistence in the first 2 years after initiating a bDMARD in a cohort of patients with RA. In addition, we classified patients as either effectively or noneffectively treated in their first year on bDMARD therapy and measured their adherence in their second year on therapy. Additional objectives explored other aspects of medication use across the first 2 years on therapy, including examination of predictors of adherence and costs.


Study Design

Claims used in this retrospective cohort study were incurred from July 1, 2008, through December 31, 2014. The index date was defined as the date of the first bDMARD claim. The preindex (baseline) period comprised the 6 months immediately preceding the index date. The postindex (follow-up) period was the 24 months immediately following the index date.

The primary objective of the study was to measure adherence to bDMARD therapies for 1 year and 2 years among patients with RA newly initiating bDMARD treatment. For this analysis, “year 1” refers to the first 12 months of treatment, “year 2” refers to months 13 to 24 of treatment, and “24 months” refers to months 1 to 24 of treatment. Adherence in the second year of therapy was assessed among patients who were effectively or noneffectively treated in the first year on therapy and among patients who were persistent or nonpersistent in the first year of therapy. The secondary objective was to explore predictors of adherence to bDMARD therapies for patients with RA newly initiating biologic treatment. Exploratory objectives included describing all-cause and RA-related costs and predictors of costs in the study population.

Data Source

This analysis was based on data obtained from the aggregated IMS PharMetrics Plus database, which comprises adjudicated claims for more than 100 million unique enrollees across the United States. Enrollees with both medical and pharmacy coverage throughout the study period represented approximately 40 million active lives on an annual basis. PharMetrics Plus provides detailed information on inpatient and outpatient diagnoses and procedures, retail and mail order prescription records, pharmacy and medical benefits (co-payment, deductible), and inpatient stays (admission type and source, discharge status).

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