Impact of anti-tumour necrosis factor alpha treatment on admissions to hospital and days of sick leave in patients with ankylosing spondylitis

Employment, Work Productivity, and Biologic Treatments in Self-Reported Axial Spondyloarthritis: a Cross-Sectional Study in a Female Predominant Population from the ArthritisPower Registry

INTRODUCTION

The aim of this study was to characterize employment, work productivity, and biologic disease-modifying anti-rheumatic drug (bDMARD) treatment in a predominantly female population of axial spondyloarthritis (axSpA) patients in a real-world setting.

METHODS

This was a cross-sectional study of axSpA participants within the ArthritisPower registry. Outcomes were assessed with surveys (Work Productivity and Activity Impairment [WPAI], Bath Ankylosing Spondylitis Disease Activity Index [BASDAI], and Patient-Reported Outcomes Measurement Information System instruments) and compared between subgroups (employed vs. not employed; taking vs. not taking a bDMARD).

RESULTS

Among the 195 participants, 117 (60.0%) were employed and 78 (40.0%) were not employed entirely or partially due to axSpA. The mean age of the participants was 47.6 years and 86.7% were female. Current bDMARD use was reported by 57.4% of those surveyed (59.8% employed vs. 53.9% not employed; p = 0.408). Compared to not employed participants, employed participants had more favorable disease activity (BASDAI 6.0 vs. 7.6; p < 0.001) and overall health (self-rated health 2.5 vs. 1.8; p < 0.001). Employed participants, compared to not employed participants, were diagnosed at an earlier age (36.0 vs. 42.5 years, respectively) and experienced a shorter time between symptom onset and diagnosis (9.5 vs. 13.6 years, respectively). Employed participants reported missing on average 6.5 days of work and experienced a 52.7% impairment on work productivity due to axSpA over a 3-month period. Absenteeism and presenteeism were statistically similar between participants taking a bDMARD versus those not taking a bDMARD.

CONCLUSIONS

Although bDMARD treatment rates were similar between employed and not employed participants, disease activity and overall health were better in employed than non-employed participants. Employed participants experienced substantial work productivity impairment due to axSpA.

Sick leave in early axial spondyloarthritis: the role of clinical and socioeconomic factors. Five-year data from the DESIR cohort

OBJECTIVES

To investigate the occurrence of sick leave (SL) and the impact of clinical and socioeconomic factors on SL in early axial spondyloarthritis (axSpA).

METHODS

Patients with a clinical diagnosis of axSpA from the DEvenir des Spondyloarthrites Indifférenciées Récentes (DESIR) cohort with work-related data and up to 5-year follow-up were studied. Incidence, time to first SL and potential role of baseline and time-varying clinical and socioeconomic factors (age, gender, ethnicity, education, job type, marital and parental status) were analysed. Univariable analyses, followed by collinearity and interaction tests, guided subsequent multivariable time-varying Cox survival model building.

RESULTS

In total, 704 axSpA patients were included (mean (SD) age 33.8 (8.6); 46% men). At baseline, 80% of patients were employed; of these, 5.7% reported being on SL. The incidence of SL among those at risk during the study period (n=620, 88%) was 0.05 (95% CI 0.03 to 0.06) per 1000 days of follow-up. Mean (SD) time to first SL was 806 (595) days (range: 175-2021 days). In multivariable models, male gender (HR 0.41 (95% CI 0.20 to 0.86)) and higher education (HR 0.48 (95% CI 0.24 to 0.95)) were associated with lower hazard of SL, while higher disease activity (HR 1.49 (95% CI 1.04 to 2.13)), older age, smoking and use of tumour necrosis factor inhibitors were associated with higher hazard of SL.

CONCLUSIONS

In this early axSpA cohort of young, working-age individuals, male gender and higher education were independently associated with a lower hazard of SL, whereas older age and higher disease activity were associated with higher hazard of SL. The findings suggest a role of socioeconomic factors in adverse work outcomes, alongside active disease.

Work Disability in Axial Spondyloarthritis

PURPOSE OF REVIEW

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that typically affects people of working age. Work-related outcomes are therefore important to study, both from an individual but also a societal perspective. Through this review of the literature, we explore the impact of axSpA on key work outcomes including work and productivity loss and predictors for these.

RECENT FINDINGS

Recent evidence confirms that axSpA is associated with substantial consequences on the ability to work. Reassuringly, early treatment and use of biologics have been associated with improved wok outcomes highlighting the importance of prompt diagnosis and management. High disease activity, labour-intensive jobs, poor physical function and impaired spinal mobility are among identified predictors of adverse work outcomes in axSpA. The impact of axSpA on work outcomes is considerable and necessitates optimal intervention, including suppression of disease activity, to enhance people's chances of remaining in work.

[Cost of illness in axial spondylarthritis for patients with and without tumor necrosis factor inhibitor treatment: results of a routine data analysis]

BACKGROUND

Tumour necrosis factor-alpha inhibitors (TNFi) are an effective but expensive treatment option in axial spondylarthritis (axSpA) patients who fail to achieve disease control under conventional treatment.

OBJECTIVE

The aim of this study was to assess the cost of illness in axSpA patients treated with and without TNFi.

METHODS

Using German health insurance data, patients with axSpA who newly received TNFi between 2011 and 2015 were identified and matched by age and sex to a reference group of patients with axSpA without TNFi treatment. Costs for services performed in an outpatient setting, inpatient care, pharmacotherapy and for productivity loss due to absence from paid work were analyzed over a 2-year period. In patients treated with TNFi , the 2‑year period included 1 year before and 1 year after the initiation of TNFi.

RESULTS

Data from 1455 axSpA patients who received TNFi treatment were included in the analyses. Costs for services performed in an outpatient setting, inpatient care, pharmacotherapy (excluding TNFi) as well as productivity loss significantly decreased after initiation of TNFi. Mean total costs increased from € 6075 in the year prior to TNFi initiation to € 27,871 in the year after TNFi initiation. Excluding costs for TNFi, total costs decreased by 22% to € 4761. Mean total costs among the reference group of 1455 age and sex-matched axSpA patients who did not receive TNFi remained stable over 2 years: € 3939 in the first year vs. € 3832 in the second year.

CONCLUSION

Initiation of TNFi treatment led to a sharp increase in the total costs of axSpA patients. Part of this increase was offset by a decrease of costs for services performed in an outpatient setting, inpatient care, pharmacotherapy (excluding TNFi) as well as productivity loss. In patients who did not receive TNFi, the costs remained stable over 2 years.

Treatment with golimumab or infliximab reduces health resource utilization and increases work productivity in patients with ankylosing spondylitis in the QUO-VADIS study, a large, prospective real-life cohort

AIM

We evaluated the effects of anti-tumor necrosis factor (TNF) agents on health economics in ankylosing spondylitis (AS) patients.

METHODS

QUality of Life as Outcomes and its VAriation with DIsease States (QUO-VADIS) was a prospective observational study following bio-naïve AS patients (modified New York criteria) newly treated with golimumab (GLM) or infliximab (IFX; originator) in a clinical practice setting over 6 months. We evaluated use of concomitant medications, hospitalizations (in-patient care or acute care) and visits in day care and out-patient settings for the assessment of healthcare resource utilization (HCRU). Work productivity and activity impairment (WPAI) was assessed by the number of work days missed and quantifying absenteeism, presenteeism, work impairment, and activity using the WPAI instrument adapted to spondyloarthritis (WPAI-SpA).

RESULTS

Nine hundred and sixty-three patients received ≥1 dose of medication (78%, n = 751 GLM; 22%, n = 221 IFX). Mean age was 42.7 years; 61.4% were male. At baseline, the percentage of patients who reported hospitalizations (in-patient care) was 13.6%, which decreased to 3.1% at 6 months, while out-patient care at baseline was reported by 39.4% of patients, which decreased to 19.0% at 6 months. The percentage of patients receiving acute emergency at baseline reduced from 1.6% to 0.3% at 6 months. The mean (SD) number of days of work missed due to AS, was reduced from 6.3 (31.1) days at baseline to 2.7 (12.3) days at 6 months.

CONCLUSION

In patients with AS newly treated with GLM or IFX for 6 months, HCRU was reduced and work productivity and activity increased.

Impact of adalimumab on clinical outcomes, healthcare resource utilization, and sick leave in patients with ankylosing spondylitis: an observational study from five Central and Eastern European countries

BACKGROUND

Patients with ankylosing spondylitis (AS) are substantial users of healthcare resources due to chronic and potentially disabling disease. This study assessed the impact of adalimumab on clinical outcomes, healthcare resource utilization, and sick leave in patients with AS in five Central and Eastern Europe (CEE) countries.

METHODS

This was an observational study in the routine clinical setting. Patients diagnosed with AS and starting treatment with originator adalimumab were followed for 12 months by assessing disease activity (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI] and Ankylosing Spondylitis Disease Activity Score [ASDAS]) and physical function (Bath Ankylosing Spondylitis Functional Index [BASFI]). Data on healthcare resource utilization and sick leave were collected prospectively and compared with historical data before adalimumab initiation, as well as between treatment responders and non-responders defined by BASDAI-50.

RESULTS

The total effectiveness population comprised 450 patients with on average long-standing AS, high disease activity, and functional impairment. At 12 months of adalimumab therapy, mean ASDAS and BASFI scores were in the range of low disease activity and normal physical function, respectively. The mean number of hospital admissions, hospital inpatient days, and healthcare provider visits were decreased by 67.9, 83.0, and 46.3%, respectively. The number and length of sick leaves were decreased by 65.6 and 81.4%, respectively. Reductions were higher in treatment responders than non-responders.

CONCLUSION

Originator adalimumab in routine clinical practice in five CEE countries produced clinically meaningful improvements in disease activity and physical function, and it was associated with reductions in healthcare resource utilization and sick leave.

Trends in hospitalization rates for psoriasis flares since the introduction of biologics: a time series in France between 2005 and 2015

BACKGROUND

In the late 2000s, the introduction of biologics transformed the prognosis for patients with moderate-to-severe psoriasis. We hypothesized that treatment with biologics may associate with a reduction in the hospitalization rate for psoriasis flares.

OBJECTIVE

To analyse changes over time in the hospitalization rate for psoriasis flares.

METHODS

We included inpatient stays in any of nine French hospitals between 2005 and 2015 for a psoriasis flare, as documented in the national inpatient database. In two centres, we also analysed data from the individual patients' electronic medical records.

RESULTS

A total of 3572 stays were included. The introduction of biologics was not associated with a decrease in the number of hospitalizations for a psoriasis flare; on the contrary, we observed a non-significant increase in the number of hospitalizations (13 hospitalizations for psoriasis flares per quarter per 10 000 beds). In the two-centre study, the introduction of biologics was associated with a significant increase in the hospitalization of patients receiving topical treatments only (520 hospitalizations per year per 10 000 beds) and those with a first psoriasis flare.

CONCLUSION

The number of hospitalizations for a psoriasis flare tended to increase between 2005 and 2015. The availability of additional treatment options might have increased patient demand and/or broadened the indications in clinical practice.

Secular trends in sickness absence among Swedish patients with ankylosing spondylitis and psoriatic arthritis

The aim was to investigate whether secular trends in sickness absence (SA) were present in patients with ankylosing spondylitis (AS) and psoriatic arthritis (PsA) receiving their diagnosis between 2002 and 2011. A repeated cross-sectional study design was used. Patients were identified in the Skåne Healthcare Register (SHR). A washout period of 18 months was applied. The general population seeking health care was used as a reference cohort. SA data from 2003 to 2012 were obtained from the Swedish Social Insurance Agency and converted into net days of SA per year. Within diagnosis and sex, the average number of net days of SA during the calendar year following diagnosis was calculated and plotted against calendar year together with the corresponding SA of the age-standardized reference population. Linear regression on aggregated data, within diagnosis and sex, was applied to formally investigate differences in secular trends among patients and referents. There were 3173 patients and 992,502 referents. Among men diagnosed with AS, the average amount of SA declined by 8.1 net days per year in patients as compared with 2.4 in the referents (p = 0.01). Among PsA patients, the average amount of SA declined by 11.7 net days per year in women as compared with 2.7 in the referents (p < 0.001) and by 7.6 net days per year in men as compared with 1.9 in the referents (p < 0.001). Secular trends of declining SA were present among AS and PsA patients. Trends were also present among the referents, although not at all of the same magnitude.

Work disability in non-radiographic axial spondyloarthritis patients before and after start of anti-TNF therapy: a population-based regional cohort study from southern Sweden

Objective

The aim was to assess work-loss days before and after commencement of anti-TNF treatment in patients with non-radiographic axial spondylarthritis (nr-axSpA).

Methods

Bionaïve nr-axSpA patients (n = 75), aged 17-62 years, fulfilling the Assessment of SpondyloArthritis international Society criteria for axial spondyloarthritis and starting anti-TNF treatment during 2004-11, were retrieved from the observational South Swedish Arthritis Treatment Group study. Patient information was linked to Swedish Social Insurance Agency data on sick leave and disability pension from 1 year before to 2 years after anti-TNF initiation. Matched population references were included for comparison and to adjust for secular trends.

Results

The nr-axSpA patients had a median age of 35 years and disease duration of 6 years at the start of treatment. During the 2 years after anti-TNF initiation, mean work-loss days (including both sick leave and disability pension) in the nr-axSpA group decreased significantly from 3.4 to 1.9 times more than among the population references. The effect was seen on sick leave, whereas disability pension levels remained similar in both groups throughout.

Conclusion

Anti-TNF therapy in nr-axSpA was associated with a significant and sustained improvement of work disability over 2 years. However, the proportion of work-loss days remained almost twice as high as in the general population at the end of follow-up.

Centre-related variability in hospital admissions of patients with spondyloarthritis

The aim of this study was to explore the variability in hospital admissions of patients with spondyloarthritis (SpA) in Spain, and the centre factors that may influence that variability. Descriptive cross-sectional study, part of the emAR II study, performed in Spain (2009-2010). Health records of patients with a diagnosis of SpA and at least one visit to the rheumatology units within the previous 2 years were reviewed. Variables related to hospital admissions, to the SpA, and to the patient and centre were collected. A multilevel logistic regression analysis of random intercept with non-random slopes was performed to assess variability between centres. From 45 centres, 1168 patients' health records were reviewed. Main SpA forms were ankylosing spondylitis (55.2 %) and psoriatic arthritis (22.2 %). A total of 248 admissions were registered for 196 patients (19.2 %, n = 1020). An adjusted variability of 17.6 % in hospitalizations between centres was noted. The following hospital-related factors showed a significant association with admissions: the total number of admissions of the centre, the existence of electronic admission, and the availability of ultrasound in rheumatology. However, these factors only explained 42.9 % of the inter-centre variability. The risk of a patient with SpA of being admitted could double (median OR 2.09), depending on the hospital where the patient was being managed. Hospital admissions of patients with SpA varied between hospitals due to centre characteristics. Further studies are needed to ascertain which specific factors may be causing the variation, as studied variables explained less than half of the variability.

Understanding Limitations in At-work Productivity in Patients with Active Ankylosing Spondylitis: The Role of Work-related Contextual Factors

Objective.

To explore the effect of health-related and contextual factors on presenteeism, absenteeism, and overall work productivity loss in patients with active ankylosing spondylitis (AS).

Methods.

Consecutive patients with AS starting their first tumor necrosis factor inhibitor and in paid employment were eligible. Patients completed the Work Productivity and Activity Impairment (WPAI) questionnaire for AS to assess presenteeism, absenteeism, and overall work productivity loss in the previous 7 days. In addition, they answered questions about work characteristics (type, characteristics of workplace, satisfaction of contacts with colleagues, and importance of work in life) and health status [Bath AS Functional Index (BASFI), AS Disease Activity Score-C-reactive protein (ASDAS-CRP)]. Physicians assessed the Bath Ankylosing Spondylitis Metrology Index, presence of articular and extraarticular manifestations, comorbidities, and laboratory indicators of inflammation. Stepwise regression models were computed to determine which work-related and health-related factors contributed to WPAI outcomes.

Results.

The study included 80 patients. The WPAI presenteeism, absenteeism, and overall work productivity loss scores were 49.1%, 30.2%, and 53.1%, respectively. Presenteeism was associated with higher BASFI, female sex, and poor quality of contact with colleagues. Absenteeism was associated with increasing age, current smoking status, higher ASDAS-CRP, and low importance of work for life. Overall work productivity loss was associated with female sex, higher BASFI, past adaptation of job because of illness, number of working hours, and manual profession.

Conclusion.

Both health-related and contextual factors contribute to work limitations in patients with AS and suggest additional opportunities for improvement by addressing the working environment.

Translation into Brazilian Portuguese, cross-cultural adaptation and validation of the Stanford presenteeism scale-6 and work instability scale for ankylosing spondylitis

Loss of productivity at work, as a result of health problems, is becoming an issue of interest due to the high burden it represents in society. The measurement of such phenomenon can be made using generic and specific scales for certain diseases such as the Stanford Presenteeism Scale (SPS-6) and the Work Instability Scale for Ankylosing Spondylitis (AS-WIS), specific for patients with ankylosing spondylitis (AS). The aim of this study was to translate and perform a cross-cultural adaptation of SPS-6 and AS-WIS into Portuguese and check their psychometric properties. The study also aimed to evaluate the relationship between the general scores of the scales and the main sociodemographic and clinical data, lifestyles, and absenteeism in patients with AS and correlate these variables with SPS-6 and AS-WIS scales. A sample of 120 patients with AS and 80 workers at a university hospital was evaluated. The processes for the translation and cross-cultural adaptation of the instruments followed preestablished steps and rules presented in the literature. For the evaluation of measurement properties and correlations between scales, intra-class correlation coefficient (reproducibility analysis), Cronbach alpha (internal consistency), and Pearson correlation coefficient (validity) were employed. The inter-observer (0.986) and intra-observer (0.992) reproducibilities of the AS-WIS were shown to be high as well as the internal consistency (0.995). Similarly, the inter-observer reliability of SPS-6 was considered good (0.890), although it showed a poorer performance when considering the same observer (Pearson correlation coefficient = 0.675 and intra-class correlation = 0.656). Internal consistency, for the total number of items, as measured by Cronbach alpha, was 0.889. The validity of the scales was evaluated thru the comparison of the achieved scores with the results of the WLQ, SF-36, ASQoL, BASFI, BASDAI, HAQ-S, and SRQ-20 instruments. Correlations between loss of productivity at work, worse quality of life, presence of emotional disturbances, and worse health conditions were positive. The process of translation, cross-cultural adaptation, and validation of the SPS-6 as a generic measurement for the loss of productivity at work and of the AS-WIS as a specific measurement for patients with AS are valid, reproducible, and specific instruments to be used in Brazil. In both scales, productivity at work was associated to advanced age, higher rate of absenteeism in the last month and year, presence of peripheral arthritis, and a larger number of comorbidities in patients with AS. The AS-WIS and SPS-6 showed a good correlation among them although they are not mutually exclusive but supplementary.

Hospitalizations of Patients Treated with Anti-Tumor Necrosis Factor-α Agents — A Retrospective Cohort Analysis

Objective.

To assess the association between treatment with anti-tumor necrosis factor-α (TNF-α) agents and the occurrence of hospitalizations, their causes and complications, compared to treatment with traditional disease-modifying antirheumatic drugs in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS).

Methods.

A retrospective cohort study was conducted of patients with RA, AS, and PsA treated with anti-TNF-α agents between April 2002 and December 2007. Patients were assessed during the period of anti-TNF-α treatment (Group B) and compared to an equivalent period before initiation of anti-TNF-α therapy (Group A). All hospitalization charts were reviewed and diagnoses, comorbidities, concomitant medications, and clinical course were analyzed. Statistical analysis was performed using multivariate mixed Poisson regression.

Results.

In the study period of 57 months, 735 hospitalization events of 327 patients were analyzed. Statistically significant decreases were seen in the total number of hospitalization events as well as hospitalizations due to exacerbation of rheumatic diseases in Group B compared to Group A (44.4 vs 74.2 and 21.9 vs 47.5 per 100 patient-years, respectively; p < 0.0001). More infectious events (7.4 in Group B compared to 4.6 per 100 patient-years in Group A; p = 0.043) were associated with anti-TNF-α treatment, older age, and underlying disease, because patients with RA had higher rates of infections compared to patients with PsA and patients with AS.

Conclusion.

The overall effect of anti-TNF-α therapy was a significant decline in total hospitalization events. The decrease was more prominent in patients with RA than in patients with AS and patients with PsA, and reflected the significant decrease in hospitalizations due to rheumatic disease exacerbation. The decrease was more pronounced than the observed increase in infectious events.

The "knowns" and "unknowns" of biologic therapy in ankylosing spondylitis

Since the first biologic agent was tested in the treatment of ankylosing spondylitis (AS), the ability of these therapies to dramatically improve the clinical symptoms and signs of the disease was very evident. Over the past decade, 4 tumor necrosis factor-alpha inhibitors have been approved by the Food and Drug Administration for the treatment of AS. Published data include randomized controlled trials, registries and observational studies. Guidelines have also been developed for the use of biologics in AS. Although a lot is known about the use of biologics in the AS, several "unknowns" remain. Whether these agents can alter the natural history of AS if started very early in the course or whether they can prevent extra-articular manifestations are among the important unanswered questions. Most of the data summarized in this review relate to tumor necrosis factor-alpha inhibitors, and other biologic agents that have been studied are included, as well. This review also summarizes what questions remain about the use of biologics in AS and what type of studies will be required to answer them.

Reduction of direct and indirect costs in patients with AS receiving etanercept: results from an open-label 36-week extension of the ASCEND study in four European countries

OBJECTIVE

To characterize the impact of etanercept (ETN) in AS on cost, work productivity and quality of life (QoL).

METHODS

A Phase 4, open-label, multi-centre (UK, Scandinavia) extension study in AS. Eligible subjects (n = 84) were treated for 36-52 weeks with ETN 50 mg s.c. once weekly. Analysis included direct costs (transformed out-patient and in-patient care elements), indirect costs (sick leave and lost working days), efficacy and QoL.

RESULTS

Annualized direct and indirect costs decreased (55.5%, P ≤ 0.008) during ETN treatment, as did out-patient and in-patient episodes (physiotherapist/physician visits, P = 0.012). Work productivity and QoL increased.

CONCLUSION

ETN therapy significantly reduces direct and indirect health-care costs and increases work ability and QoL in AS. Trial Registration. EUDRACT, https://eudract.ema.europa.eu/, 2006-001061-42.

Sick leave in patients with ankylosing spondylitis before and after anti-TNF therapy: a population-based cohort study

OBJECTIVE

To study levels of sick leave and disability pension before and after TNF-antagonist therapy in AS patients.

METHODS

Using the population-based South Swedish Arthritis Treatment Group register, we identified 139 AS patients (aged 18-58 years, 78% men), who between January 2002 and December 2008 started their first treatment with adalimumab, etanercept or infliximab. We linked data to the payment register by the Swedish Social Insurance Agency and calculated the proportion on sick leave in 30-day intervals from 12 months before treatment start until 12 months after. For each AS patient, we randomly selected four subjects from the general population matched for age, sex and area of residence.

RESULTS

One to 3 months before treatment, an average of 24% of AS patients were on sick leave. During the first 6 months after treatment start, this fraction dropped to 15%, and further declined to 12% at 12 months (P < 0.001). Comparing AS patients with the general population, the relative risk of being on sick leave 3 months before treatment, treatment start and 12 months after treatment start was 8.0 (95% CI 4.6, 13.9), 9.2 (95% CI 5.4, 15.7) and 4.0 (95% CI 2.1, 6.3), respectively. The decrease in sick leave was not substantially offset by changes in disability pension.

CONCLUSION

There is a decline in sick leave during the first 12 months after initiation of TNF-antagonist treatment in AS patients not explained by societal factors or secular trends. The proportion of AS patients on disability pension remained unchanged during the observation period.

Cost of Illness from the Public Payers’ Perspective in Patients with Ankylosing Spondylitis in Rheumatological Care

Objective.

To estimate the incremental costs to public payers for patients with ankylosing spondylitis (AS) of working age compared with reference subjects from the general population.

Methods.

We investigated total costs for 3 years (2005–2007) in 116 outpatients under 66 years of age with AS attending rheumatological care in Malmö, Sweden. Mean (SD) age was 46 (11) years and mean (SD) disease duration was 24 (11) years. Two subjects per AS patient matched for age, sex, and residential area were selected from the Population Register to serve as a reference group. We retrieved data concerning sick leave, prescription drugs, and healthcare consumption from Swedish health-cost registers by the unique personal identification numbers.

Results.

The mean total cost for the 3-year period 2005–2007 was US $37,095 (SD $30,091) for patients with AS, and $11,071 (SD $22,340) for the reference group. The mean indirect cost was $19,618 and $5905, respectively. Mean cost for healthcare was $8998 for the AS patients and $4187 for the reference subjects, and mean cost for drugs was $8479 and $979, respectively. The patients with AS treated with biological therapy constituted 80% of the total drug cost, but just 40% of the cost for disability pension.

Conclusion.

Patients with AS had 3-fold increase in costs compared to reference subjects from the general population, and the drug costs were almost 10 times as high. Production losses (indirect cost) represented more than half of total cost (53%).

Impact of Age, Sex, Physical Function, Health-related Quality of Life, and Treatment with Adalimumab on Work Status and Work Productivity of Patients with Ankylosing Spondylitis

Objective.

To determine factors associated with work in patients with ankylosing spondylitis (AS).

Methods.

Three hundred fifteen patients with AS were enrolled in a 24-week, randomized controlled study of adalimumab with a longterm, open-label, adalimumab extension phase. Patient-reported outcome (PRO) measures included the Medical Outcome Study Short Form 36 Health Survey (SF-36), AS Quality of Life Questionnaire (ASQOL), Health Utilities Index Mark 3 (HUI-3), and Work Productivity and Activity Impairment-Specific Health Problem Questionnaire (WPAI-SHP). Multivariate logistic regression was used to analyze differences between working and nonworking patients. The relationships between PRO and WPAI-SHP scores were assessed using Pearson correlation coefficients. Multivariate modeling was applied to determine factors associated with productivity while at work. WPAI-SHP was assessed through 3 years of adalimumab exposure.

Results.

Younger age (p = 0.002) and male sex (p < 0.001) were significantly and independently associated with working patients with AS. The SF-36 Physical Component Summary score (p < 0.001), ASQOL score (p < 0.001), HUI-3 scores (p < 0.001), and both patient’s global assessment of disease activity (p < 0.001) and nocturnal pain (p < 0.001) scores were independently associated with working status. Work absenteeism due to AS was weakly correlated with all PRO scores. WPAI-SHP components of work presenteeism (lack of productivity at work), activity impairment, and overall work productivity loss due to AS were moderately correlated with quality of life as measured by the ASQOL, the SF-36 Physical Component Summary score, and the SF-36 Bodily Pain domain. Linear multivariate analyses indicated that work presenteeism was significantly associated with pain, functioning, and disease activity. Longterm adalimumab treatment was associated with sustained improvements in WPAI-SHP scores.

Conclusions.

Quality of life and the physical consequences associated with AS have a direct relationship with a patient’s ability to work. Adalimumab sustains improvements in work outcomes in patients with AS.

Patients with ankylosing spondylitis have increased sick leave--a registry-based case-control study over 7 yrs

OBJECTIVES

Using prospectively collected registry data to investigate sick leave (sickness benefit and sickness compensation) over a 7-yr period in patients with AS in comparison with population-based controls matched for age, sex and residential area.

METHODS

We investigated 122 (21 women and 101 men) outpatients with AS in South Sweden, born 1942 or later, from rheumatology specialist care for their sick leave during a 7-yr period. Mean (S.D.) age was 43 (11) yrs and mean (S.D.) disease duration was 20 (11) yrs. Two controls per case, matched for age, sex and residential area were selected from the Swedish National Population Register. Data concerning sick leave for cases and controls, based on the subjects' unique 10-digit personal identification number, were retrieved from the national register of the Swedish Social Insurance Agency.

RESULTS

More AS patients than controls were registered for sickness benefit (52 vs 36%, P < 0.01) and sickness compensation (42 vs 11%, P < 0.001). Cases had an increased risk for sick leave compared with controls with a relative risk of 1.8; 95% CI 1.5, 2.1; and cases had more days with sick leave than controls (median number of more days per year 30; 95% CI 2, 72).

CONCLUSIONS

Using the Swedish Social Insurance Agency's registers for sick leave, we found that patients with AS in rheumatology specialist care in South Sweden have an increased level of sick leave compared with controls. These population-based registers have a great potential for studies of the effects of different interventions on sick leave.

Infliximab in the treatment of ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic, progressive disease characterized by inflammation in the spine and sacroiliac joints which causes pain, stiffness and the potential for spinal ankylosis. It is associated with significant functional impairment. It is common and since onset is often in young people, the burden of disease is considerable. Conventional treatment including non-steroidal antiinflammatory drugs (NSAIDs) and physiotherapy have proven but limited efficacy in controlling symptoms and preventing progression of spinal manifestations. Infliximab, a chimeric monoclonal antibody which binds to and inhibits tumor necrosis factor alpha (TNFalpha), is highly effective in controlling disease activity in AS. In AS, infliximab 5 mg/kg body weight is usually given as an infusion at weeks 0, 2 and 6, and then every 6-8 weeks. When infliximab is used in combination with NSAIDs a rapid improvement in disease activity by at least 50% is seen in as many as 50% of AS patients. Infliximab has been shown to have ongoing efficacy for as long as regular infusions continue and is safe in the medium term. Magnetic resonance studies show major reductions in spinal inflammation during treatment with infliximab, however ongoing studies will assess if infliximab has disease modifying effect in AS.

Sick leave and work disability in patients with early arthritis

We studied the occurrence of sick leave and work disability, the presence of workplace adaptations and the usage of professional guidance related to working problems in patients with early arthritis. Inclusion criteria were arthritis symptoms of less than 2 years duration and a paid job at the time of diagnosis. Assessments were done in connection with an early arthritis clinic (EAC) at entry into the cohort and 12 months thereafter by means of a questionnaire comprising questions on sick leave (absenteeism from work reported to the employer), work disability (receiving a full or partial work disability pension), unemployment, work adaptations and professional guidance related to working problems. Fifty-seven of the 69 participants (83%) had an arthritis symptom duration of <6 months. The number of patients with sick leave due to arthritis in the past 12 months decreased from 28 (41%) at study entry to 18 (26%) after 12 months of follow-up. The number of patients receiving a work disability pension increased from 5 (7%) at study entry to 13 (19%) after 12 months of follow-up (10 partial and 3 full). Sick leave in the 12 months before study entry appeared to be the most important predictor of the institution or increase in a work disability pension (odds ratio, 16.1; 95%CI, 1.8–142.8). Between study entry and follow-up, the number of patients with workplace adaptations increased from 20 (29%) to 28 (42%), whereas the number of patients receiving vocational guidance decreased from 48 (70%) to 36 (52%). In patients with early arthritis and a paid job, arthritis-related sick leave was common and occurred in part before patients entered the EAC and a diagnosis was made. About 20% of the patients became permanently work disabled, with partial work disability being more common than full work disability. Considerable proportions of patients received workplace adaptations and professional guidance with working problems.

The impact of anti-tumour necrosis factor therapy for rheumatoid arthritis on the use of other drugs and hospital resources in a pragmatic setting

BACKGROUND

Anti-tumour necrosis factor (anti-TNF) therapy has been an important development for the treatment of rheumatoid arthritis (RA) but the impact of its delivery on hospital resources in still emerging.

AIMS

We audited the effect of starting anti-TNF on the use of other anti-rheumatic therapies and hospital resources in a routine secondary care setting.

METHODS

A retrospective study of resource use before and after anti-TNF was conducted. Hospital records of 54 RA patients were studied and data taken from the time of commencing anti-TNF to 1 October 2004 and an equal time period prior to commencing anti-TNF. Identical data were collected for 54 controls not on anti-TNF. Relevant figures were extrapolated to per annum rates. Results were analysed using two-factor ANOVAs comparing the pre- versus post-anti-TNF period. Cases on intravenous (IV) versus subcutaneous (SC) anti-TNF were also compared in separate ANOVAs.

RESULTS

Mean duration of anti-TNF therapy was 17.04 months (range 3.60-42.36). Mean pre- and 3-months post-anti-TNF Disease Activity Scores (DAS28) were 6.93 and 3.88, respectively. Cases were more likely than controls to be on oral prednisolone pre- and post-anti-TNF. Methylprednisolone requirement, number of disease-modifying anti-rheumatic drugs (DMARDs), telephone helpline contacts and duration as an inpatient reduced significantly post-anti-TNF. Day case admissions increased but outpatient appointments decreased only in cases on IV anti-TNF.

CONCLUSIONS

In a pragmatic setting, anti-TNF therapy led to reduced need for steroid injections and other DMARDs, as well as reductions in use of several hospital resources. Wider replication of these findings will be important for planning delivery.

Drug Insight: anti-tumor-necrosis-factor therapy for ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disorder of the spine and peripheral joints that can lead to significant disability if left untreated. Conventional treatments can be successful in alleviating symptoms; however, this approach has not been shown to halt the progression of disease. The proinflammatory cytokine tumor necrosis factor (TNF) is central to the pathogenesis of AS. Several anti-TNF drugs have been developed and have been shown to control symptoms effectively, and possibly to prevent both clinical and radiographic progression of disease, in patients with AS. This review discusses the data from clinical trials that have assessed the use of TNF inhibitors in patients with AS, and briefly outlines other biologic therapies that have been studied.

Infliximab for the treatment of ankylosing spondylitis

Ankylosing spondylitis (AS) had previously been considered as a chronic disease with little therapeutic options. Non-steroidal anti-inflammatory drugs (NSAIDs) and regular physiotherapy were the only treatment modalities available for patients with AS. The introduction of biologics into clinical practice has substantially broadened the therapeutic armamentarium in AS patients who are refractory to NSAIDs. Remicade (infliximab; Centocor, Inc., USA), a chimeric monoclonal antibody, targets TNF-alpha, and by inhibition of this proinflammatory cytokine, exerts strong clinical improvement of signs and symptoms of AS. In AS, infliximab 5 mg/kg body weight is usually given as an infusion at weeks 0, 2 and 6, and every 6 - 8 weeks thereafter. An improvement of the disease activity by at least 50% is seen in as many as 50% of AS patients treated with infliximab in addition to NSAIDs. Back pain and also peripheral manifestations, such as enthesitic sites and arthritis, improve, and quality of life significantly increases. In addition, elevated acute phase reactants return to normal or low levels, and active inflammatory lesions of the spine as detected by magnetic resonance imaging substantially regress during treatment with infliximab. Clinical improvement occurs during the first 2 weeks of treatment and the clinical response to infliximab, if given continuously, is sustained and long-lasting as follow-up data of ongoing studies show. The short-term benefit/risk ratio of infliximab is clearly in favour of the drug, and it is estimated that at present up to 30% of patients with active AS are in need of this kind of effective treatment.

Infliximab improves productivity and reduces workday loss in patients with ankylosing spondylitis: Results from a randomized, placebo-controlled trial

OBJECTIVE

To examine whether clinical benefits observed after treatment with infliximab were accompanied by improvement in productivity and reduction in time lost from work in a randomized, double-blind, placebo-controlled, multicenter trial of patients with ankylosing spondylitis (AS).

METHODS

Adults with active AS receiving standard antiinflammatory treatment were randomly assigned in a 3:8 ratio to receive infusions of placebo or 5 mg/kg infliximab at weeks 0, 2, 6, and every 6 weeks thereafter through week 24. Physical function was measured using the Bath Ankylosing Spondylitis Functional Index. The impact of disease on productivity was measured using a visual analog scale (range 0-10). Self-reported employment status and time lost at work before and during the trial were collected. Spearman's correlation coefficient was used to examine factors associated with productivity.

RESULTS

Patients treated with infliximab had a more significant reduction in limitations of work and daily activity due to physical or emotional problems than patients treated with placebo. Of the subset of patients employed full time, patients in the infliximab group had a significantly greater improvement in productivity as early as week 6 compared with the placebo group. The median change from baseline in the productivity score at week 24 was 0.7 (median percent change 11%) in the placebo group compared with 2.1 (62%) in the infliximab group (P < 0.05). Daily productivity was significantly correlated with physical function and disease activity at baseline and week 24.

CONCLUSION

The daily productivity of patients with active AS was significantly associated with functional impairment and disease activity. Infliximab treatment significantly improved productivity and reduced workday loss among employed patients with AS.

Therapy of ankylosing spondylitis. Part II: biological therapies in the spondyloarthritides

Therapeutic options for patients with active and severe spondylarthritis (SpA) have been fairly limited in the past decades. There is now accumulating evidence that biological therapy with agents directed against tumour necrosis factor-alpha (TNF-alpha) is highly efficacious in the spondyloarthritides, especially in ankylosing spondylitis (AS) and psoriatic arthritis (PsA). The TNF blocking agents currently available, infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira), are approved for the treatment of rheumatoid arthritis (RA) in Europe and the USA. In contrast to rheumatoid arthritis (RA) disease-modifying anti-rheumatic drugs (DMARDs) have limited efficacy in SpA. No DMARDs are available for AS patients with active spinal disease. Thus, for AS patients whose condition is not sufficiently controlled with non-steroidal anti-inflammatory drugs (NSAIDs), therapy with TNF blockers may be considered as a first-line treatment. For infliximab, a dose of 3-5 mg/kg seems to be required, and intervals between 6 and 12 weeks are necessary to suppress disease activity continually. The standard dosage of etanercept is 2 x 25 mg subcutaneously (s.c.) per week. There are very few studies with adalimumab (standard dose in RA 20-40 mg s.c. every 1-2 weeks) in SpA. Infliximab and etanercept are now both approved for AS in Europe. There is some evidence that both agents also work in other SpA, especially in PsA. Withdrawal of long-term therapy in AS patients led to relapses of disease after several months. Less radiographic progression after 2 years of continuous treatment with infliximab compared to conventional therapy has been suggested in a small study. Serious adverse events on anti-TNF therapy have remained rare. However, severe infections, including tuberculosis, have been reported. These can be largely prevented by appropriate screening. The benefits of anti-TNF therapy in AS seem to outweigh these shortcomings.

First update of the international ASAS consensus statement for the use of anti-TNF agents in patients with ankylosing spondylitis

OBJECTIVE

To update the international recommendations for use of anti-tumour necrosis factor (TNF) agents in the treatment of ankylosing spondylitis.

METHODS

The published recommendations on anti-TNF treatment in ankylosing spondylitis formed the basis of the update. A questionnaire was sent to the ASAS (assessment in ankylosing spondylitis) members before the final decisions were agreed upon at an international meeting of the ASAS working group.

RESULTS

Only minor changes to the original consensus statement were required. For the initiation of anti-TNF treatment, there should be: a diagnosis of definitive ankylosing spondylitis (normally based on modified New York criteria); active disease for at least four weeks, as defined by a sustained Bath ankylosing spondylitis disease activity index (BASDAI) of > or =4 on a 0-10 scale and expert opinion based on clinical findings; refractory disease, defined by failure of at least two non-steroidal anti-inflammatory drugs during a three month period, failure of intra-articular steroids (if indicated), and failure of sulfasalazine in patients with predominantly peripheral arthritis; and application of the usual precautions and contraindications for biological treatment. For monitoring anti-TNF treatment: both the ASAS core set for clinical practice and the BASDAI should be followed after the initiation of treatment. Discontinuation of anti-TNF treatment in non-responders should be considered after 6-12 weeks. Response is defined by improvement of at least 50% or 2 units (on a 0-10 scale) of the BASDAI.

CONCLUSIONS

This updated consensus statement is recommended in guiding clinical practice and as a basis for developing national guidelines. Evaluation and regular update of this consensus statement is subject to further research by the ASAS group.

Novel therapies for ankylosing spondylitis

Recent interest in therapeutic developments for ankylosing spondylitis has focused primarily on two anti-tumor necrosis factor-a therapies, infliximab and etanercept, with several reports establishing their efficacy in pivotal phase III trials. Open extension analyses of earlier controlled trials have also shown that efficacy is maintained for at least 3 years, that monotherapy is adequate, and that treatment is well tolerated with few serious infections. Treatment is associated with reduction in sick leave and days spent in hospital. Despite induction of antinuclear antibodies and anti-ds DNA antibodies, clinical sequelae are rare. Reduction in magnetic resonance imaging parameters of inflammation and serologic biomarkers of cartilage turnover suggest that these agents may be disease-modifying though direct evidence from plain radiographic studies is still lacking. Conventional second line therapies typically used in rheumatoid arthritis have also been examined and while leflunomide appears to possess limited efficacy, there may be a case for re-examining the value of methotrexate.

Outcome of patients with active ankylosing spondylitis after two years of therapy with etanercept: Clinical and magnetic resonance imaging data

OBJECTIVE

To examine the long-term outcome of patients with active ankylosing spondylitis (AS) clinically and by magnetic resonance imaging (MRI) after continuous treatment with the tumor necrosis factor (TNF) receptor fusion protein etanercept over 2 years.

METHODS

Overall, 26 patients with active AS were treated with etanercept 25 mg twice daily subcutaneously, twice weekly with no concomitant disease-modifying antirheumatic drugs (DMARDs) or steroids. The clinical response was assessed by standardized parameters. Inflammatory spinal lesions were quantified by the ASspiMRI-a rating gadolinium-enhanced (T1-weighted gadolinium diethylenetriaminepentaacetic acid) and STIR MRI sequences. The primary outcome was a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) improvement > or =50% after 2 years of etanercept therapy compared with the baseline value of the study.

RESULTS

Overall, 21 (70%) of 30 patients completed year 2. In the intent-to-treat analysis, 54% of the patients showed a 50% improvement according to the BASDAI and a 40% improvement according to the Assessment in Ankylosing Spondylitis (ASAS) criteria. In the completer analysis, 9 (43%) of 21 patients were in partial remission according to ASAS criteria. Mean +/- SD BASDAI scores, which were elevated at baseline (6.3 +/- 1.6), remained low: 2.7 +/- 2.4 after 2 years compared with 2.6 +/- 2.2 at week 54. In accordance, all other clinical parameters showed sustained improvement during year 2. The majority of patients had no disease activity flares. MRI evaluation showed a 75% improvement of active spinal lesions, but minor spinal inflammation was still present in 64% of the patients after 2 years. There were 2 serious adverse events leading to discontinuation of etanercept.

CONCLUSION

The clinical efficacy and safety of etanercept in patients with active AS without simultaneous administration of DMARDs or steroids over 2 years of continuous treatment is confirmed. Spinal inflammation as depicted by MRI decreased significantly, but a few patients still had some spinal inflammation even after long-term anti-TNF therapy.