Reasons for discontinuation of subcutaneous biologic therapy in the treatment of rheumatoid arthritis: a patient perspective

Figures & data

Figure 1 Study inclusion and exclusion criteria.

Abbreviations: RA, rheumatoid arthritis; SQ, subcutaneous; TNF, tumor necrosis factor.

Table 1 Surveyed reasons for discontinuation

Category	Reason
Unprompted section
Lack of effectiveness	–
Miscellaneous	Prefer other medication
	Doctor’s advice
	Remission
	Other
Administration	Injection
	Miscellaneous
Cost/insurance coverage	–
Safety/side effects/tolerability	–
Comorbidity/contraindication	–
Did not know	–
Prompted section
Effectiveness	Loss of effectiveness after initial relief
	Took too long to relieve symptoms
	Therapy never relieved symptoms
Injection experience	Pain/burning/discomfort during injection
	Pain/burning/discomfort after injection
	Injection reactions
	Dislike of self-injection
	Dislike of injection frequency
	Fearful of injection
Cost/insurance coverage	Could no longer afford
	Difficulty obtaining approval
Safety	Experienced infection
	Fearful of infection
	Other safety concern
Other	–
Remission	–

Table 2 Patient characteristics

Patient characteristics	Patients, % (n=250)
Sex
Female	72.8
Male	27.2
Ethnicity
Non-white	19.2
White	80.8
Relationship status
Married/committed relationship	70.0
Not married/no committed relationship	30.0
Education status
College or further educated	58.0
Less than college educated	42.0
Employment status
Full-time, part-time, or self-employed	61.2
Unemployed, homemaker, retired, disabled, student	38.8
Income
< US$50,000	30.4
> US$50,000	63.2
Information missing	6.4
Age, years
21–40	20.4
41–50	26.0
51–55	19.2
56–65	24.4
66–85	10.0
BMI
Underweight	1.2
Normal weight	28.4
Overweight	30.0
Obese	34.0
Information missing	6.4
Health insurance
Managed care (HMO, PPO)	54.4
Medicare	3.2
Medicaid	23.6
Individual/family insurance plan	26.4
VA CHAMPUS	2.0
US region
Northeast	29.6
Midwest	21.2
South	24.4
West	24.4

Abbreviations: BMI, body mass index; HMO, Health Maintenance Organization; PPO, Preferred Provider Organization; VA, Veterans’ Affairs; CHAMPUS, Civilian Health and Medical Program of the Uniformed Services.

Table 3 Patient discontinuation characteristics

Discontinuation characteristics	Patients, % (n=250)
Subcutaneous anti-TNF discontinued
Adalimumab	39.2
Certolizumab	9.6
Etanercept	43.6
Golimumab	7.6
Other RA therapy taken at the time of discontinuation
NSAIDs	43.6
Steroids	25.2
Nonbiologic DMARDs	38.0
Other	2.8
Severity of RA at initiation of treatment
Mild	8.4
Moderate	53.2
Severe	38.4
Change in RA condition while taking anti-TNF therapy
Worsened	12.4
Stable	44.4
Improved	43.2
Switching
Discontinued therapy without switching	48.0
Discontinued and switched therapy	52.0
The decision to discontinue
Physician suggested immediate stop	17.6
Physician asked patient to consider stop	27.6
Patient initiated discussion, and physician agreed	43.6
Patient initiated discussion, but physician disagreed	3.6
Patient did not discuss with physician	7.6

Abbreviations: RA, rheumatoid arthritis; NSAIDs, nonsteroidal anti-inflammatory drugs; DMARDs, disease-modifying antirheumatic drugs; TNF, tumor necrosis factor.

Figure 2 Relative frequency of reasons for discontinuation.

Notes: Combined data report the proportion of patients citing each reason as either a primary or secondary cause of discontinuation. This applies only to the prompted section of the questionnaire, as unprompted primary/secondary reasons were not mutually exclusive.

Table 4 Reasons for discontinuation

Reasons	Patients, %a
Unprompted reasons	Primary (n=297)	Secondary (n=270)
Lack of effectiveness	40.4	19.6
Safety/side effects/tolerability	32.0	18.4
Miscellaneous	19.2	9.2
Prefer other medication	4.8	2.8
Doctor’s advice	8.8	4.0
Remission	2.8	0.8
Other	3.2	2.0
Administration	10.0	9.2
Injection	8.4	8.0
Miscellaneous	1.6	2.0
Cost/insurance coverage	10.0	8.4
Comorbidity/contraindication	5.6	2.8
Did not know	1.6	5.6
No reason	0	34.8
Prompted reasons	Primary (n=250)	Secondary (n=331)	Combinedb (n=462)
Remission	7.2	3.2	10.4
Effectiveness	40.8	27.6	60.8
Loss of effectiveness after initial relief	20.0	12.4	32.4
Took too long to relieve symptoms	4.0	10.0	14.0
Therapy never relieved symptoms	16.8	7.2	24.0
Injection experience	18.4	34.0	40.8
P/B/D during injection	4.4	8.8	13.2
P/B/D after injection	3.6	10.8	14.4
Injection reactions	4.0	8.4	12.4
Dislike of self-injection	1.6	10.0	11.6
Dislike of injection frequency	3.6	6.8	10.4
Fearful of injection	1.2	5.6	6.8
Cost/insurance coverage	12.0	21.2	27.6
Could no longer afford	6.8	11.2	18.0
Difficulty obtaining approval	5.2	11.2	16.4
Safety	11.6	17.6	26.0
Experienced infection	4.0	3.6	7.6
Fearful of infection	1.6	6.8	8.4
Other safety concern	6.0	7.2	13.2
Other	10.0	9.2	19.2

Notes:

a Some participants gave unprompted responses that covered more than one category for their primary reason (n=297), hence percentages do not sum to 100%. However, prompted primary reasons were mutually exclusive and do sum to 100%. Patients could select multiple secondary reasons for both sections.

b The percentage of patients citing the reason as either a primary or secondary cause of discontinuation, which were mutually exclusive in the prompted section.

Abbreviation: P/B/D, pain/burning/discomfort.

Table 5 Patient-rated severity of injection issues and timing of physician consultations

Patient experience	Injection issue (patients, %)
	P/B/D during injection					P/B/D after injection					Injection reactions
	Primary reason (n=38)	Secondary reason (n=68)	Primary/secondary reason (n=79)	Experienced but not a reason (n=133)	Overall experienced (n=143)	Primary reason (n=37)	Secondary reason (n=69)	Primary/secondary reason (n=81)	Experienced but not a reason (n=114)	Overall experienced (n=125)	Primary reason (n=29)	Secondary reason (n=62)	Primary/secondary reason (n=69)	Experienced but not a reason (n=100)	Overall experienced (n=112)
Severity of injection issue
Very severe	7.9	5.9	5.1	2.3	3.5	2.7	5.8	4.9	9.6	8.8	10.3	9.7	10.1	19.0	17.0
Severe	28.9	19.1	24.1	15.0	15.4	16.2	20.3	22.2	31.6	30.4	27.6	32.3	31.9	35.0	34.8
Moderate	42.1	44.1	43.0	42.9	43.4	62.2	55.1	55.6	45.6	45.6	37.9	41.9	40.6	30.0	32.1
Mild	18.4	26.5	24.1	32.3	30.8	13.5	15.9	14.8	12.3	13.6	17.2	12.9	14.5	15.0	14.3
Very mild	2.6	4.4	3.8	7.5	7.0	5.4	2.9	2.5	0.9	1.6	6.9	3.2	2.9	1.0	1.8
Consultation with physician
Immediate	23.7	30.9	27.8	21.8	21.0	32.4	36.2	32.1	27.2	26.4	48.3	45.2	43.5	34.0	33.9
At next appointment	57.9	52.9	53.2	51.9	52.4	51.4	46.4	49.4	50.9	51.2	37.9	40.3	42.0	46.0	44.6
Never	18.4	16.2	19.0	26.3	26.6	16.2	17.4	18.5	21.9	22.4	13.8	14.5	14.5	20.0	21.4

Note: Each injection experience was reported by patients in multiple ways to ensure full capture of the experience: 1) as the main reason for discontinuing in either the prompted or unprompted sections; 2) as another reason for discontinuing in either the prompted or unprompted sections; 3) as either the main reason or another reason for discontinuing in either the prompted or unprompted sections; 4) as experienced when previously using the discontinued medication outside the context of a reason for discontinuation; 5) as a combination of all of the above categories.

Abbreviation: P/B/D, pain/burning/discomfort.