BACKGROUND: Patients with rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, or ulcerative colitis may require treatment with a biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD). Often, a tumor necrosis factor inhibitor (TNFi) is the initial b/tsDMARD. The TNFi may not be effective or may not be well tolerated, so patients will opt for a different TNFi or switch to a non-TNFi b/tsDMARD. No preference for TNFi or non-TNFi has been established and guidelines are unclear.
OBJECTIVE: To evaluate effectiveness by comparing patients using a second TNFi versus a non-TNFi after initial use of TNFi based on treatment patterns and healthcare utilization.
METHODS: This retrospective analysis used Medicare Advantage with Prescription Drug (MAPD), Medicaid, and commercial plan claims data from Humana’s Research Database (Louisville, KY). The first claim for TNFi or non-TNFi (7/1/2016 – 6/30/2018) following earlier TNFi was the index date. Patients were required to have pre-index enrollment of 6 months and 12 months post-index along with diagnosis of RA, PsA, AS, CD, UC or PsO. During the 12-month follow-up, persistence to the index TNFi or non-TNFi was measured as continued therapy without a gap exceeding 45 days (81 days for IV infusions). Adherence was proportion of days covered ≥0.8. Addition of a non-biologic DMARD or corticosteroid was also identified. Inpatient admissions and emergency department visits were observed. Inverse probability of treatment weights was used to balance cohorts. Logistic regression models were fit to TNFi to non-TNFI on treatment and utilization measures.
RESULTS: Of identified patients, 1,022 were indexed to a second TNFi and 1,024 were indexed to non-TNFi. Weighted cohorts were balanced, with mean age 56.5 vs 56.4 years, 70.5% vs 70.7% female, and 68.0% vs 67.9% MAPD. No differences were observed on persistence or adherence, with adjusted odds ratios (OR) of 1.05 (95% CI 0.91-1.20) and 1.04 (0.91-1.20) respectively. No differences were observed for changes in therapy via switching to another TNFi/non-TNFi (OR 0.93 CI 0.54-1.62), via non-biologic DMARD addition (OR 0.95 CI 0.83-1.11), or corticosteroid addition (OR 1.09 CI 0.92-1.88). No differences were observed for hospitalization (OR 1.16 CI 0.99-1.37) or emergency department visits (OR 1.02 CI 0.89-1.18).
CONCLUSIONS: No differences were found between a second TNFi versus a non-TNFi. As a result, choice of TNFi or non-TNFi following an initial TNFi may be driven by relevant patient-specific considerations. At the population level, policies that prefer either TNFi or non-TNFi appear reasonable.
