Outcomes of tumor necrosis factor inhibitor cycling versus switching to a disease-modifying anti-rheumatic drug with a new mechanism of action among patients with rheumatoid arthritis

Abstract

Objectives: To examine treatment patterns, treatment effectiveness, and treatment costs for 1 year after patients with rheumatoid arthritis switched from a tumor necrosis factor inhibitor (TNFi) (adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab), either cycling to another TNFi (“TNFi cyclers”) or switching to a new mechanism of action (abatacept, tocilizumab, or tofacitinib) (“new MOA switchers”).

Methods: This retrospective cohort study used administrative claims data for a national insurer. Treatment persistence (without switching again, restarting, or discontinuing), treatment effectiveness (defined below), and costs were assessed for the 12-month post-switch period. Patients were “effectively treated” if they satisfied all six criteria for a treatment effectiveness algorithm (high adherence, no dose increase, no new conventional synthetic disease-modifying anti-rheumatic drug, no subsequent switch in therapy, no new/increased oral glucocorticoids, and <2 glucocorticoid injections). Multivariable logistic models were used to adjust for baseline factors.

Results: The database included 581 new MOA switchers and 935 TNFi cyclers. New MOA switchers were 39% more likely than TNFi cyclers to persist after the switch (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.12–1.74; p = .003) and 36% less likely to switch therapy again (OR = 0.64; 95% CI = 0.51–0.81; p < .001). New MOA switchers were 43% more likely than TNFi cyclers to be effectively treated (OR = 1.43; 95% CI = 1.11–1.85; p = .006). New MOA switchers had 16% lower drug costs than TNFi cyclers (cost ratio = 0.84; 95% CI = 0.79–0.88; p < .001) and 11% lower total costs of rheumatoid arthritis-related medical care (cost ratio = 0.89; 95% CI = 0.84–0.94; p < .001).

Limitations: Claims payments may not reflect rebates or other cost offsets. Medical and pharmacy claims do not include clinical end-points or reasons that lead to new MOA switching vs TNFi cycling.

Conclusions: These results support switching to a new MOA after a patient fails treatment with a TNFi, which is consistent with recent guidelines for the pharmacologic management of established rheumatoid arthritis.

Keywords:

• Rheumatoid arthritis
• switching
• tumor necrosis factor inhibitor
• disease-modifying anti-rheumatic drugs
• treatment effectiveness

Transparency

Declaration of funding

Employees of the study sponsors (Regeneron Pharmaceuticals and Sanofi) participated in the design and analysis of the study and the preparation of this article.

Declaration of financial/other relationships

BC and LKB are employees of Optum, which received funding from Regeneron Pharmaceuticals and Sanofi to conduct the research. CIC is an employee and stockholder of Regeneron Pharmaceuticals. PM is an employee and stockholder of Sanofi. JRC is a paid consultant to Regeneron Pharmaceuticals. Peer reviewers on this manuscript have received an honorarium from JME for their review work, but have no other relevant financial relationships to disclose.

Acknowledgments

Jonathan Latham of PharmaScribe, LLC, received funding from Regeneron Pharmaceuticals to assist the authors with the preparation and submission of the manuscript. The authors thank George J. Joseph, PhD, MS, for contributions to the study conception and design.