Psoriasis treatment patterns: a retrospective claims study

Real-world treatment patterns and healthcare costs in patients with psoriasis taking systemic oral or biologic therapies

BACKGROUND

Psoriasis is a chronic, immune-mediated, systemic inflammatory disorder associated with high costs. This study evaluated real-world treatment patterns and associated costs in patients in the United States with psoriasis initiating systemic oral or biologic treatments.

METHODS

This retrospective cohort study used IBM^® (now Merative™) MarketScan^® Commercial and Medicare claims (1 January 2006-31 December 2019) to evaluate patterns of switching, discontinuation, and nonswitching in two cohorts of patients initiating oral or biologic systemic therapy. Total pre-switch and post-switch costs were reported per-patient per-month (PPPM).

RESULTS

Each cohort was analyzed (oral, n = 11,993; biologic; n = 9753). Among the oral and biologic cohorts, 32% and 15% discontinued index and any systemic treatment within 1 year of initiation; 40% and 62% remained on index therapy; and 28% and 23% switched treatment, respectively. In the oral and biologic cohorts, total PPPM costs within 1 year of initiation for nonswitchers, patients who discontinued, and patients who switched were $2594, $1402, and $3956, respectively, and $5035, $3112, and $5833, respectively.

CONCLUSION

This study identified lower persistence in the oral treatment cohort, higher costs associated with switching, and a need for safe and effective oral treatment options for patients with psoriasis to delay the switch to biologic therapy.

Apremilast Adherence and Persistence in Patients with Psoriasis and Psoriatic Arthritis in the Telehealth Setting Versus the In-person Setting During the COVID-19 Pandemic

INTRODUCTION

Limited access to healthcare during the COVID-19 pandemic prompted patients to seek care using telehealth. In this study, we assessed whether treatment patterns differed for patients with psoriasis (PsO) or psoriatic arthritis (PsA) initiating apremilast by either a telehealth or an in-person visit.

METHODS

We estimated adherence and persistence among US patients in the Merative© MarketScan© Commercial and Supplemental Medicare Databases who newly initiated apremilast between April and June 2020, categorized by the type of visit (telehealth or in-person) when apremilast was first prescribed. Adherence was defined as the proportion of days covered (PDC), with PDC ≥ 0.80 considered to indicate high adherence. Persistence was defined as having apremilast available to take without a 60-day gap during follow-up. Factors associated with high adherence and persistence were estimated with logistic and Cox regression.

RESULTS

Among apremilast initiators (n = 505), the mean age was 47.6 years, 57.8% were female, and the majority had PsO (79.6%). Telehealth index visits were more likely among patients residing in Northeast USA (odds ratio [OR] 3.31, 95% confidence interval [CI] 1.63-6.71) and Western USA (OR 2.52, 95% CI 1.07-5.93]), those with a prescribing rheumatologist (OR 2.27, 95% CI 1.10-4.68), and those with any baseline telehealth visit (OR 1.91, 85% CI 1.20-3.04). Those initiating apremilast with a telehealth visit (n = 141) had similar mean PDC to those initiating apremilast with an in-person visit (n = 364) (0.695 vs. 0.728; p = 0.272). At the end of the 6-month follow-up, 54.3% of the overall population had high adherence (PDC ≥ 0.80) and 65.1% were persistent. After adjusting for potential confounders, patients initiating apremilast via telehealth had similar full adherence (OR 0.80, 95% CI 0.52-1.21) and persistence as those initiating apremilast in-person.

CONCLUSION

Patients with PsO and patients with PsA initiating apremilast via telehealth or in-person during the COVID-19 pandemic had similar medication adherence and persistence during the 6-month follow-up period. These data suggest that patients initiating apremilast can be as effectively managed with telehealth visits as with in-person visits.

Suboptimal Clinical and Quality of Life Outcomes in Patients with Psoriasis Undertreated with Oral Therapies: International Physician and Patient Survey

INTRODUCTION

Psoriasis is a chronic, inflammatory, immune-mediated disease. This study assessed the time at which patients switched from a conventional oral systemic treatment to a biologic therapy; patient clinical and quality of life (QoL) outcomes associated with oral systemic treatments; and the proportion of patients who persisted on oral therapy (nonswitchers), despite reported suboptimal clinical and QoL outcomes.

METHODS

This data analysis used the Adelphi Real World Psoriasis Disease Specific Programme, a non-interventional, retrospective, cross-sectional survey conducted in the USA, France, Germany, and United Kingdom (August 2018-April 2019). Kaplan-Meier (KM) analysis assessed switching from oral to biologic therapy in patients treated ≥ 3 years at survey completion (n = 597). The severity of psoriasis was reported by physicians as the percentage of body surface area (BSA) affected by psoriasis. Dermatology Life Quality Index (DLQI) scores were calculated for three groups: nonswitchers who met treatment failure criteria, nonswitchers who did not meet failure criteria, and switchers to a biologic therapy.

RESULTS

In KM analysis, approximately 50% of the patient population switched by 24 months. A substantial portion of nonswitchers continued to have moderate-to-severe psoriasis. Among nonswitchers, 57-77% had BSA ≥ 3% and 16-24% had BSA ≥ 10% at the time of the survey compared with 37% of switchers who had BSA of ≥ 3% and 9% who had BSA of ≥ 10%. QoL was poor among nonswitchers. The mean [standard deviation (SD)] DLQI scores for nonswitchers meeting treatment failure criteria, nonswitchers not meeting failure criteria, and switchers were 6.11 (4.55), 2.62 (3.29), and 2.25 (4.23), respectively.

CONCLUSION

There is a clear unmet need for more effective oral therapies, and further research into the reasons for patients remaining undertreated, which may include patient preference for oral treatments (despite lack of response), contraindications, or insurance/formulary-related barriers to access, are needed.

Treatment Patterns for Targeted Therapies, Non-Targeted Therapies, and Drug Holidays in Patients with Psoriasis

Introduction

We aimed to evaluate US treatment patterns and, more specifically, switch patterns among patients with psoriasis (PsO) who initiated treatment with targeted therapy (TT) and subsequently switched to another therapy.

Methods

This retrospective study used IBM^® MarketScan^® Commercial and Medicare Databases (1/1/2006–3/31/2020) to evaluate treatment patterns in biologic- and apremilast-naive patients with PsO. TT included apremilast, adalimumab, etanercept, infliximab, ustekinumab, or other biologics (certolizumab pegol, secukinumab, brodalumab, ixekizumab, guselkumab, or tildrakizumab). Adults with ≥ 1 prescription for a TT, ≥ 2 PsO claims separated by ≥ 1 day on or before the index date (date of first TT prescription), and continuous medical and pharmacy enrollment for 1 year before and 2 years after the index date were eligible. Non-targeted therapy (NTT) was defined as non-targeted oral systemic treatment, topical treatment, phototherapy, or no treatment. Kaplan–Meier (KM) analysis was used to estimate time to reinitiation of TT (24-month continuous enrollment post-index was not required).

Results

A total of 11,526 patients with PsO were included; mean [standard deviation (SD)] age and Charlson Comorbidity Index score were 48.3 (12.8) years and 0.9 (1.43), respectively. During the follow-up, 69.2% of the patients were treated with NTT. Median time to first NTT, for those who received NTT, was 205 days (longest: adalimumab, 252 days). Among patients who switched to NTT after initiating treatment with TT, 52.6% reinitiated treatment with TT (least common: apremilast, 45.6%), with a median time to reinitiation of 106 days (longest: other biologics, 136 days). For all patients on NTT, the probability of reinitiating any TT was 60.7% at 24 months.

Conclusions

PsO treatment is often cyclical in nature. Patients frequently experience drug holidays or transition back to TT after using NTT. The consideration of real-world treatment patterns in future economic models may provide new insights into the clinical effectiveness and value of PsO treatments.

Psoriasis is a chronic inflammatory skin disease that affects 3.0% of adults or an estimated 7.56 million Americans. The most common type of psoriasis is called plaque psoriasis because of its appearance with red patches and silvery scales on the skin. A major concern of medical providers is that not all patients continue their treatment as prescribed. Many patients discontinue, switch, and often restart treatment. To develop effective psoriasis treatment plans for shared decision-making among medical providers and patients, it is important to look at how treatments are used in the real world. This can be done by conducting studies using insurance claims data from healthcare insurance providers. In this study, we evaluated treatment patterns and, more specifically, patterns in changes of treatment in US patients who began their psoriasis treatment with a targeted therapy (biologics or apremilast) and then changed to another therapy. We found that patients often took drug holidays (days with no treatment) and returned back to using a targeted therapy after using a non-targeted therapy (e.g., other oral therapy, topical treatment, phototherapy, or no treatment). Findings from this real-world study may support future studies on the clinical effectiveness and value of current and future treatments for psoriasis—especially within these targeted to non-targeted transitions.

Biologic Initiation Rate in Systemic-Naïve Psoriatic Arthritis Patients Starting Treatment with Apremilast vs Methotrexate: 1-Year Retrospective Analysis of a US Claims Database

Purpose

To compare the rate of biologic initiation after commencing treatment with apremilast (APR) vs methotrexate (MTX), in systemic-naïve patients with psoriatic arthritis (PsA).

Patients and Methods

Systemic-naïve patients with PsA who started treatment with either APR or MTX between 01/01/2015 and 12/31/2018 were analyzed using claims data from the IBM^® MarketScan^® Commercial and Medicare Supplemental databases (2014-2019). PsA patients were identified via diagnosis codes; the first prescription date for APR or MTX was the index date. Patient demographics, clinical characteristics, healthcare utilization during the year pre-index (baseline) and the year post-index (follow-up), and median time to biologic initiation were reported descriptively. The rates and risk of biologic initiation during follow-up were compared between APR and MTX users by logistic and Cox regressions, respectively. Models were adjusted for demographics, clinical and utilization measures during the baseline period.

Results

A total of 2116 patients with PsA newly treated with APR (n = 534) or MTX (n = 1582) were identified. Mean age was similar (50.5 vs 50.4; P = 0.938), and proportion of females was higher for APR vs MTX users (59.4% vs 54.0%; P = 0.031). Mean time to biologic initiation among patients who initiated during follow-up was 194.1 vs 138.7 days between APR vs MTX users (P < 0.001). After adjusting for confounders, the likelihood of biologic initiation was 58% lower (OR, 0.42 [95% CI, 0.32-0.54]; P < 0.001) with APR, with a significantly lower predicted rate of biologic initiation among APR users when compared to MTX users during follow-up (20.0% [95% CI, 16.6-23.9%] vs 37.5% [95% CI, 35.0-40.1%]). Additionally, APR users had a lower risk of biologic initiation than MTX users (HR, 0.46 [95% CI, 0.37-0.57]; P < 0.001) during the 1-year follow-up.

Conclusion

Systemic-naïve patients with PsA have a lower rate of, and longer time to, biologic initiation over one-year following APR initiation, compared to those initiating MTX.

Biologic initiation rates in systemic-naive psoriasis patients after first-line apremilast versus methotrexate use

Aim: To compare rates of biologic initiation after commencing treatment with apremilast (APR) versus methotrexate (MTX) in systemic-naive patients with psoriasis (PsO). Methods: This was a retrospective cohort study of systemic-naive patients with PsO who initiated treatment with APR or MTX between 1 January 2015 and 31 March 2018. Outcomes: Adjusted rates of biologic initiation during follow-up were compared by logistic and Cox regressions. Results: APR initiators had 58% lower likelihood of biologic initiation (odds ratio: 0.42; 95% CI: 0.37-0.48; p < 0.001), lower adjusted biologic initiation rate (14.4% [95% CI: 13.2-15.7%] vs 28.6% [95% CI: 26.8-30.5%]), lower risk of biologic initiation (hazard ratio: 0.45; 95% CI: 0.40-0.51; p < 0.001) compared with MTX initiators. Conclusion: Systemic-naive patients with PsO have a lower rate of biologic initiation over 1 year following APR initiation.

Risk of Treatment Discontinuation among Patients with Psoriasis Initiated on Ustekinumab and Other Biologics in the USA

Introduction

Biologics are a standard therapy for patients with moderate-to-severe psoriasis, yet treatment persistence is essential to achieve disease control. Compared with other biologics, ustekinumab has been associated with lower rates of discontinuation and better adherence among patients with psoriasis, but prior studies have included limited data from the period after approval of self-administration for ustekinumab. This study was conducted to assess discontinuation risk among patients with plaque psoriasis initiating ustekinumab or other biologics.

Methods

Adults with psoriasis and one or more claim for ustekinumab, secukinumab, adalimumab, or ixekizumab were identified in Optum’s de-identified Clinformatics Data Mart Database (1 January 2010 to 30 June 2019). Treatment discontinuation was defined as a gap in days of therapy supply based on (1) each drug’s per-label frequency of administration (main analysis) or (2) > 90 days (sensitivity analysis). Differences in baseline characteristics between the ustekinumab and other cohorts were adjusted with entropy balancing. Risk of discontinuation was compared with Cox proportional hazard models.

Results

Overall, 2230 patients were included in the ustekinumab cohort, with 1807 in the secukinumab, 4483 in the adalimumab, and 535 in the ixekizumab cohorts (mean age 49.0 years, 49.3% female for all cohorts). In the main analysis, risk of discontinuation for the ustekinumab cohort was 62.2% lower than for adalimumab, 46.4% lower than for secukinumab, and 43.8% lower than for ixekizumab cohorts (all p < 0.001). Sensitivity analyses revealed no significant differences between the ustekinumab and other cohorts.

Conclusions

Patients with psoriasis initiating ustekinumab had lower risk of treatment discontinuation compared with other biologics when discontinuation was based on each drug’s per-label frequency of administration. This finding may help inform choice of biologic based on compliance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00707-z.

Adherence and Persistence to Biological Drugs for Psoriasis: Systematic Review with Meta-Analysis

Despite the large number of biologics currently available for moderate-to-severe psoriasis, poor adherence and persistence to therapy represent the main issues for both the clinical and economic management of psoriasis. However, the data about adherence and persistence to biologics in psoriasis patients are conflicting. Our aim was to produce summary estimates of adherence and persistence to biologics in adult patients with psoriasis. We performed a systematic review and meta-analysis of observational studies, searching two databases (PubMed and Embase). Sixty-two records met the inclusion criteria, and a meta-analysis was conducted on fifty-five studies. Overall, the proportion of adherent and persistent patients to biological therapy was 0.61 (95% confidence interval: 0.48–0.73) and 0.63 (0.57–0.68), respectively. The highest proportions were found for ustekinumab, while the lowest ones were found for etanercept. The proportions of adherence and persistence to biological drugs in psoriasis patients are sub-optimal. Notably, both proportions largely differ between drugs, suggesting that a more rational use of biologics might ensure better management of psoriasis.

Sex Differences in the Patterns of Systemic Agent use Among Patients With Psoriasis: A Retrospective Cohort Study in Quebec, Canada

Background: Sex differences exist in psoriasis manifestation and expectations from treatment with systemic agents, including, conventional systemic agents (CSA) and tumor necrosis factor inhibitors or ustekinumab (TNFi/UST). However, sex differences in patterns of systemic agent use, such as CSA discontinuation and switch from CSA to TNFi/UST have not been examined.

Objectives: To assess sex differences in patterns of CSA use and identify factors associated with switch to (or add) a TNFi/UST and those associated with CSA discontinuation.

Methods: We conducted a retrospective cohort study using the Quebec health administrative databases. We included patients with psoriasis initiating a CSA in 2002–2015. We excluded patients with a psoriasis diagnosis in the 3 years prior to the first diagnosis date between 2002 and 2015, and those with a systemic agent dispensation in the year prior to that date. We used Cox regression models with the Least Absolute Shrinkage and Selection Operator method to identify factors associated with Switch/add TNFi/UST, and those associated with CSA discontinuation. Separate analyses were performed for male and female patients.

Results: We included 1,644 patients (55.7% females, mean age 60.3 years), among whom 60.4% discontinued their CSA and 7.4%, switched/added TNFi/UST (3.4% switched and 4.0% added) within a median of 0.78 years of follow-up. Among male and female patients, rates of Switch/add TNFi/UST per 1,000 person-year were 49.1 and 41.0 and rates of CSA discontinuation were 381.2 and 352.8. Clinical obesity in male patients (HR 3.53, 95% CI 1.20–10.35), and adjustment/somatoform/dissociative disorders (HR 3.17, 95% CI 1.28–7.85) and use of nonsteroidal anti-inflammatory drugs (HR 2.70, 95% CI 1.56–4.70) in female patients were associated with Switch/add TNFi/UST. Male patients followed by a rheumatologist (HR 0.66, 95% CI 0.46–0.94) and those with a prior hospitalization (HR 0.70, 95% CI 0.57–0.87) were at lower risk of CSA discontinuation, while those initiated on acitretin (vs methotrexate) were at higher risk to discontinue their CSA (HR 1.61, 95% CI 1.30–2.01). Female patients with rheumatoid arthritis comorbidity (HR 0.69, 95% CI 0.51–0.93), those with a dispensed lipid-lowering agent (HR 0.72, 95% CI 0.59–0.88) and hypoglycemic agent (HR 0.75, 95% CI 0.57–0.98) and those initiated on methotrexate (vs all other CSAs) were less likely to discontinue their CSA. Male and female patients entering the cohort between 2011 and 2015 were at reduced risk of CSA discontinuation compared to those entering the cohort before 2011.

Conclusion: Most male and female patients discontinued their CSA within 1 year of follow-up. Our study highlighted sex differences in patients’ characteristics associated with switch/add a TNFi/UST and CSA discontinuation; treatment switch and discontinuation may be indications of treatment failure in most patients.

Effectiveness of oral vitamin D supplementation in lessening disease severity among patients with psoriasis: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Many treatment modalities have been used to manage psoriasis; however, there is, to our knowledge, no pooled estimate for the effectiveness of oral vitamin D supplements in patients with psoriasis. Hence, the aim of the present study was to systematically review and meta-analyze the efficacy of oral vitamin D supplementation in lessening disease severity of patients with psoriasis.

METHODS

A systematic literature review was performed on the electronic databases PubMed, Embase, and Cochrane Central and the gray literature for retrieving randomized controlled trials comparing oral vitamin D supplementation with placebo. The primary outcome was the change of Psoriasis Area and Severity Index (PASI) score. We used the random effects model for synthesizing the evidence.

RESULTS

Of the total 5018 search results, 4 studies were included in the qualitative and 3 studies in quantitative analysis. Vitamin D supplementation was effective in ameliorating the PASI score after 6 mo of intervention (mean difference [MD] = -0.92, 95% confidence interval [CI] = -1.72 to -0.11). However, after the Hartung-Knapp adjustment, the results became non-significant (MD = -0.92, 95% CI = -2.21 to 0.38).

CONCLUSIONS

A favorable effect of oral vitamin D supplementation in patients with psoriasis could not be verified. More randomized controlled trials with larger sample sizes are needed to produce robust results.