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van der Schoot LS, Janssen JJ, Bastiaens MT, de Boer-Brand A, Christiaansen-Smit C, Enomoto DNH, Hovingh R, Tupker RA, Seyger MMB, Verhoef LM, van den Reek JMPA, de Jong EMGJ. Steps towards implementation of protocolized dose reduction of adalimumab, etanercept and ustekinumab for psoriasis in daily practice. J DERMATOL TREAT 2023; 34:2186728. [PMID: 36867069 PMCID: PMC10013325 DOI: 10.1080/09546634.2023.2186728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Dose reduction (DR) of adalimumab, etanercept and ustekinumab has proven to be (cost-)effective in psoriasis patients with low disease activity. Further implementation is needed to establish application of DR for eligible patients. OBJECTIVES To evaluate the implementation of protocolized biologic DR in daily practice. METHODS A pilot implementation study was performed in 3 hospitals during 6 months. By combining education and protocol development, involved healthcare providers (HCPs) were directed toward the adoption of protocolized DR. DR of adalimumab, etanercept, and ustekinumab was achieved by stepwise injection interval prolongation. Implementation outcomes (fidelity, feasibility) were assessed. Factors for optimizing implementation were explored in interviews with HCPs. Uptake was measured in patients by chart review. RESULTS The implementation strategy was executed as planned. Implementation fidelity was less than 100% as not all provided tools were used across study sites. HCPs indicated the feasibility of implementing protocolized DR, although time investment was needed. Identified additional factors for successful implementation included support for patients, uptake of DR into guidelines, and supportive electronic health record systems. During the 6 months intervention period, 52 patients were eligible for DR of whom 26 (50%) started DR. The proposed DR protocol was followed in 22/26 patients (85%) on DR. CONCLUSION Additional staff for support, extra time during consultations, education on DR for HCPs and patients, and effective tools such as a feasible protocol can lead to more patients on biologic DR.
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Affiliation(s)
- L S van der Schoot
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J J Janssen
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M T Bastiaens
- Department of Dermatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - A de Boer-Brand
- Department of Dermatology, St Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - C Christiaansen-Smit
- Department of Dermatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - D N H Enomoto
- Department of Dermatology, Dermatologisch Centrum Isala, Zwolle, The Netherlands
| | - R Hovingh
- Department of Dermatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - R A Tupker
- Department of Dermatology, St Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - M M B Seyger
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - J M P A van den Reek
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud University, Nijmegen, The Netherlands
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Spekhorst LS, Boesjes CM, Loman L, Zuithoff NPA, Bakker DS, Kamphuis E, Kamsteeg M, Haeck IM, Oosting AJ, van Lumig PPM, van Lynden-van Nes AMT, Tupker RA, Flinterman A, Garritsen FM, Touwslager WRH, de Bruin-Weller MS, Schuttelaar MLA, de Graaf M. Successful tapering of dupilumab in patients with atopic dermatitis with low disease activity: a large pragmatic daily practice study from the BioDay registry. Br J Dermatol 2023; 189:327-335. [PMID: 37177895 DOI: 10.1093/bjd/ljad159] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/05/2023] [Accepted: 05/06/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Limited data are available regarding patient-centred dosing of dupilumab for atopic dermatitis (AD) in daily practice. OBJECTIVES To evaluate our patient-centred dupilumab dosing regimen in daily practice, to assess prognostic factors for successful tapering and to estimate medication-related cost savings. METHODS This prospective multicentre study included adult patients with AD, participating in the BioDay registry, treated with dupilumab for ≥ 1.3 years. Interval prolongation was considered in the case of dupilumab standard dose for ≥ 1 year and persistent controlled AD [Eczema Area and Severity Index (EASI) ≤ 7; ≥ 6 months]. Primary endpoints were the mean EASI and Numeric Rating Scale (NRS)-pruritus after the start of tapering. Prognostic factors for successful tapering were analysed with logistic regression and a cost-savings analysis was performed. RESULTS A total of 595 patients were included, of whom 401 patients [mean EASI 2.5 (SD 2.3); NRS-pruritus of 2.4 (SD 1.9) at the start of tapering] prolonged their dupilumab interval. In 83.3% of these patients tapering was successful; most patients used dupilumab every 3 or 4 weeks (Q3W/Q4W). A significant small increase was observed for EASI (highest mean 3.5) and NRS-pruritus (highest mean 3.2) (P < 0.001); however, scores remained low. Predicting successful tapering showed nonsignificant odds ratios for all incorporated variables. The estimated cost savings was €3 977 033.98 for 401 patients between January 2019 and June 2022. CONCLUSIONS This study showed successful tapering of dupilumab in 83.3% of patients with AD who attempted tapering, while maintaining controlled disease and with the majority using Q3W/Q4W. Interval prolongation can be beneficial both for the patient and from a socio-economic perspective.
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Affiliation(s)
- Lotte S Spekhorst
- National Expertise Center for Atopic Dermatitis, Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Celeste M Boesjes
- National Expertise Center for Atopic Dermatitis, Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Laura Loman
- Department of Dermatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Nicolaas P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daphne S Bakker
- National Expertise Center for Atopic Dermatitis, Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Esmé Kamphuis
- Department of Dermatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Marijke Kamsteeg
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Inge M Haeck
- Department of Dermatology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Albert J Oosting
- Department of Dermatology, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Paula P M van Lumig
- Department of Dermatology, University Medical Center Maastricht, Maastricht, the Netherlands
| | | | - Ron A Tupker
- Department of Dermatology, St Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | | | - Marjolein S de Bruin-Weller
- National Expertise Center for Atopic Dermatitis, Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Marlies de Graaf
- National Expertise Center for Atopic Dermatitis, Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, the Netherlands
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Egeberg A, Freilich J, Stelmaszuk MN, Kongerslev R, Apol E, Hansen JB, Levin L. Real-world dose adjustments of biologic treatments in psoriasis and their economic impact: a Swedish national population study. Clin Exp Dermatol 2022; 47:1968-1975. [PMID: 35670046 PMCID: PMC9826076 DOI: 10.1111/ced.15288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND To date, evidence on the dose adjustments of biologics in the real-world treatment of psoriasis is limited. However, dose adjustments may have important clinical and economic implications. AIMS To study the dose adjustments of individual biologics over time in real-world practice in Sweden. METHODS A retrospective observational study of adults with moderate to severe psoriasis was conducted based on Swedish national registry data from 2010 to 2018. Treatment episodes were identified for individual patients from the date of drug dispensation to the end of the supply of the drug. Dosing data were expressed as the proportion of treatment episodes with accumulated syringes/vials equal to, above or below the recommended guidelines. Real-world costs were calculated and compared with costs predicted from dosing guidelines. RESULTS The mean dose was above recommended levels for all biologics investigated. Weighted mean dose adjustments for adalimumab, etanercept, secukinumab and ustekinumab were 13%, 23%, 8% and 3%, respectively, over the entire treatment period. Higher doses translate to higher costs, including notable increases over time vs. expected costs for secukinumab. CONCLUSIONS Dose adjustments of biologics are frequent in clinical practice but differ for the various biologics. The mean observed increases in dose above guideline recommendations might indicate perceptions of suboptimal efficacy for biologics, with implications for the cost and cost-effectiveness of these treatments. Further research is warranted to understand the reasons for dose adjustments in clinical practice.
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Affiliation(s)
- Alexander Egeberg
- Department of DermatologyBispebjerg Hospital, University of CopenhagenCopenhagenDenmark
| | - Jonatan Freilich
- Department of Public Health and Clinical MedicineUmeå UniversityUmeåSweden,Parexel InternationalStockholmSweden
| | | | | | | | | | - Lars‐Åke Levin
- Department of Health, Medicine and Caring Sciences (HMV)Linköping UniversityLinköpingSweden
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4
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van der Schoot LS, van den Reek JMPA, Grine L, Schots L, Kievit W, Lambert JLW, de Jong EMGJ. Dose reduction of the new generation biologics (IL-17 and IL-23 inhibitors) in psoriasis: study protocol for an international, pragmatic, multicenter, randomized, controlled, non-inferiority study-the BeNeBio study. Trials 2021; 22:707. [PMID: 34656148 PMCID: PMC8520290 DOI: 10.1186/s13063-021-05681-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 10/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Psoriasis is a chronic immune-mediated inflammatory skin disease for which biologics are effective treatments. Dose reduction (DR) of the first generation biologics seems a promising way for more efficient use of expensive biologics. A substantial part of patients on tumor necrosis factor (TNF)-alfa inhibitors and ustekinumab could successfully lower their dose, after following a tightly controlled DR strategy. The objective of this study is to assess whether controlled DR of interleukin (IL)-17 and IL-23 inhibitors in psoriasis patients with low disease activity is non-inferior (NI) to usual care (UC). METHODS This is an international, prospective, multicenter, pragmatic, randomized, non-inferiority trial. A total of 244 patients with stable low disease activity (Psoriasis Area and Severity Index (PASI) ≤ 5) for at least 6 months and using secukinumab, ixekizumab, brodalumab, guselkumab, risankizumab, or tildrakizumab in the standard dose, together with stable low disease activity, defined as a PASI ≤ 5 and Dermatology Life Quality Index (DLQI) ≤ 5 at the moment of inclusion, will be randomized 2:1 to DR or UC. In the DR group, dosing intervals will be prolonged stepwise to achieve 66% and 50% of the original dose. Disease activity is monitored every 3 months by PASI and DLQI. In case of disease flare (i.e., PASI and/or DLQI increase), treatment is adjusted to the previous effective dose. The primary outcome is the incidence proportion of persistent flares (PASI > 5 for ≥ 3 months), which will be compared between arms. Secondary outcomes include proportion of patients with successful DR, (course of) PASI and DLQI, serious adverse events (SAEs), health-related quality of life, costs, and pharmacokinetic profile. Outcomes of DR will be compared to UC. DISCUSSION With this study, we aim to assess whether DR of IL-17 and IL-23 inhibiting biologics can be achieved for psoriasis patients with low disease activity, without losing disease control. Reducing the dose may lead to more efficient use of biologics. TRIAL REGISTRATION ClinicalTrials.gov NCT04340076 . Registered on April 9 2020.
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Affiliation(s)
- Lara S van der Schoot
- Radboud University Medical Center, Department of Dermatology, Rene Descartesdreef 1, 6525GL, Nijmegen, The Netherlands.,Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Juul M P A van den Reek
- Radboud University Medical Center, Department of Dermatology, Rene Descartesdreef 1, 6525GL, Nijmegen, The Netherlands.,Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Lynda Grine
- Department of Dermatology, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Lisa Schots
- Department of Dermatology, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Wietske Kievit
- Radboud University Medical Center, Department for Health Evidence, Geert Grooteplein 21, 6525EZ, Nijmegen, The Netherlands
| | - Jo L W Lambert
- Department of Dermatology, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Elke M G J de Jong
- Radboud University Medical Center, Department of Dermatology, Rene Descartesdreef 1, 6525GL, Nijmegen, The Netherlands. .,Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands. .,Radboud University, Comeniuslaan 4, 6525HP, Nijmegen, The Netherlands.
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Atalay S, van den Reek JMPA, Groenewoud JMM, van de Kerkhof PCM, Kievit W, de Jong EMGJ. Two-year follow-up of a dose reduction strategy trial of biologics adalimumab, etanercept, and ustekinumab in psoriasis patients in daily practice. J DERMATOL TREAT 2021; 33:1591-1597. [PMID: 33356686 DOI: 10.1080/09546634.2020.1869147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND/OBJECTIVES Tightly-controlled dose reduction was possible during 1 year in psoriasis patients on adalimumab, etanercept or ustekinumab with low disease activity (CONDOR trial). Extended observation is needed to ensure long-term effectiveness and safety of the strategy. With prolonged follow-up, we investigated the clinical effects and safety of the strategy, the proportion of patients with successful dose reduction, and assessed if patients with a disease flare regained remission. METHODS Two-year follow up of a subgroup of patients previously included in a randomized pragmatic study comparing usual care (UC) with stepwise dose reduction (DR). Effectiveness (Psoriasis Area and Severity Index, PASI), Dermatology Life Quality Index (DLQI), adverse events, proportion of patients with successful DR and proportion of persistent disease flares were analyzed. RESULTS DR leads temporarily to a slightly increased PASI groupwise, but on the long-term patients regained low PASI. DLQI scores remained stable during follow-up. No serious adverse events due to DR were reported. Forty-one percent of patients remained on a low dose up to 2 years. The number of persistent flares was low in DR and UC. CONCLUSIONS The proposed dose reduction strategy is effective for a significant part of patients and remains safe up to 2 years of follow-up.
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Affiliation(s)
- S Atalay
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J M P A van den Reek
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J M M Groenewoud
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P C M van de Kerkhof
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - W Kievit
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud University, Nijmegen, The Netherlands
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6
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Atalay S, van den Reek JMPA, den Broeder AA, van Vugt LJ, Otero ME, Njoo MD, Mommers JM, Ossenkoppele PM, Koetsier MI, Berends MA, van de Kerkhof PCM, Groenewoud HMM, Kievit W, de Jong EMGJ. Comparison of Tightly Controlled Dose Reduction of Biologics With Usual Care for Patients With Psoriasis: A Randomized Clinical Trial. JAMA Dermatol 2020; 156:393-400. [PMID: 32049319 DOI: 10.1001/jamadermatol.2019.4897] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Biologics revolutionized the treatment of psoriasis. Biologics are given in a fixed dose, but lower doses might be possible. Objective To investigate whether dose reduction (DR) of biologics in patients with stable psoriasis is noninferior to usual care (UC). Design, Setting, and Participants This pragmatic, open-label, prospective, controlled, noninferiority randomized clinical trial was conducted from March 1, 2016, to July 22, 2018, at 6 dermatology departments in the Netherlands. A total of 120 patients with plaque psoriasis and stable low disease activity who were receiving treatment with adalimumab, etanercept, or ustekinumab were studied. Interventions Patients were randomized 1:1 to DR (n = 60) or UC (n = 60). In the DR group, injection intervals were prolonged stepwise, leading to 67% and 50% of the original dose. Main Outcomes and Measures The primary outcome was between-group difference in disease activity corrected for baseline at 12 months compared with the predefined noninferiority margin of 0.5. Secondary outcomes were Psoriasis Area and Severity Index (PASI) score and health-related quality of life (including Dermatology Life Quality Index [DLQI] and Medical Outcomes Study 36-Item Short Form Health Survey scores), proportion of patients with short and persistent flares (defined as PASI and/or DLQI scores >5 for ≥3 months), and proportion of patients with successful dose tapering. Results Of 120 patients (mean [SD] age, 54.0 [13.2] years; 82 [68%] male), 2 patients were lost to follow-up, 2 patients had a protocol violation, and 5 patients had a protocol deviation, leaving 111 patients for the per-protocol analysis (53 in the DR group and 58 in the UC group). The median PASI scores at month 12 were 3.4 (interquartile range [IQR], 2.2-4.5) in the DR group and 2.1 (IQR, 0.6-3.6) in the UC group (mean difference, 1.2; 95% CI, 0.7-1.8). This indicates that noninferiority was not demonstrated for DR compared to UC. The median DLQI score at month 12 was 1.0 (IQR, 0.0-2.0) in the DR group and 0.0 (IQR, 0.0-2.0) in the UC group (mean difference, 0.8; 95% CI, 0.3-1.3), indicating noninferiority for DR compared with UC. No significant difference was found regarding persistent flares between groups (n = 5 in both groups). Twenty-eight patients (53%; 95% CI, 39%-67%) in the DR group tapered their dose successfully at 12 months. No severe adverse events related to the intervention occurred. Conclusions and Relevance In this trial, noninferiority was not demonstrated for DR of adalimumab, etanercept, and ustekinumab based on the PASI in patients with psoriasis compared with UC with the chosen noninferiority margin. However, the strategy was noninferior based on the DLQI. Dose tapering did not lead to persistent flares or safety issues. Trial Registration ClinicalTrials.gov Identifier: NCT02602925.
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Affiliation(s)
- Selma Atalay
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | - Lieke J van Vugt
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marisol E Otero
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marcellus D Njoo
- Department of Dermatology, Ziekenhuis Groep Twente, Hengelo, the Netherlands
| | - Johannes M Mommers
- Department of Dermatology, Sint Anna Ziekenhuis, Geldrop, the Netherlands
| | | | | | - Maartje A Berends
- Department of Dermatology, Slingelandziekenhuis, Doetinchem, the Netherlands
| | | | | | - Wietske Kievit
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Elke M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
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7
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Pharmacogenetics Update on Biologic Therapy in Psoriasis. ACTA ACUST UNITED AC 2020; 56:medicina56120719. [PMID: 33419370 PMCID: PMC7766592 DOI: 10.3390/medicina56120719] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/06/2020] [Accepted: 12/17/2020] [Indexed: 02/06/2023]
Abstract
Background and objectives: Psoriasis is a chronic immune-mediated skin disease caused by several complex factors, both environmental and genetic, many of which are still not fully understood. Nowadays, several groups of biological drugs are being used for psoriasis treatment. Although these therapies are very effective, they show significant variability in efficacy among individuals. Therefore, there is a need for biomarkers to predict treatment outcomes in order to guide personalized therapeutic decisions. Pharmacogenetics is the study of variations in DNA sequences related to drug response. Materials and Methods: In this article, we review pharmacogenetics studies on the treatment of moderate-to-severe psoriasis focusing on anti-interleukin (IL) 12/23 (ustekinumab) and anti-IL17 drugs (secukinumab and ixekizumab), as well as recent studies concerning anti-TNF drugs. Results: Several polymorphisms have been studied over the years in reference to anti-TNF drugs; some of the most recent studies included the performance of a genome-wide association study (GWAS) and pharmacogenetics studies focused on the optimization of a treatment regimen. Various polymorphisms in different genes have been related to ustekinumab response; among them, the most commonly studied is the HLA-C*06:02 allele. Conclusions: Although not confirmed in some studies, most studies have shown that patients carrying this allele present a significantly higher response rate to ustekinumab. Some polymorphisms have been studied in patients treated with anti-IL17 drugs, mostly related to secukinumab; however, up to now, no association has been found between any of these polymorphisms and response. Nevertheless, further studies involving larger cohorts are needed in order to confirm these results before the implementation of this biomarker in clinical practice.
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Smits LJT, Pauwels RWM, Kievit W, de Jong DJ, de Vries AC, Hoentjen F, van der Woude CJ. Lengthening adalimumab dosing interval in quiescent Crohn's disease patients: protocol for the pragmatic randomised non-inferiority LADI study. BMJ Open 2020; 10:e035326. [PMID: 32461297 PMCID: PMC7259868 DOI: 10.1136/bmjopen-2019-035326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Adalimumab is effective for maintenance of remission in patients with Crohn's disease (CD) at a dose of 40 mg subcutaneously every 2 weeks. However, adalimumab is associated with (long-term) adverse events and is costly. The aim of this study is to demonstrate non-inferiority and cost-effectiveness of disease activity guided adalimumab interval lengthening compared to standard dosing of every other week (EOW). METHODS AND ANALYSIS The Lengthening Adalimumab Dosing Interval (LADI) study is a pragmatic, multicentre, open label, randomised controlled non-inferiority trial. Non-inferiority is reached if the difference in cumulative incidence of persistent (>8 weeks) flares does not exceed the non-inferiority margin of 15%. 174 CD patients on adalimumab maintenance therapy in long-term (>9 months) clinical and biochemical remission will be included (C-reactive protein (CRP) <10 mg/L, faecal calprotectin (FC) <150 µg/g, Harvey-Bradshaw Index (HBI) <5). Patients will be randomised 2:1 into the intervention (adalimumab interval lengthening) or control group (adalimumab EOW). The intervention group will lengthen the adalimumab administration interval to every 3 weeks, and after 24 weeks to every 4 weeks. Clinical and biochemical disease activity will be monitored every 12 weeks by physician global assessment, HBI, CRP and FC. In case of disease flare, dosing will be increased. A flare is defined as two of three of the following criteria; FC>250 µg/g, CRP≥10 mg/l, HBI≥5. Secondary outcomes include cumulative incidence of transient flares, adverse events, predictors for successful dose reduction and cost-effectiveness. ETHICS AND DISSEMINATION The study is approved by the Medical Ethics Committee Arnhem-Nijmegen, the Netherlands (registration number NL58948.091.16). Results will be published in peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBERS EudraCT registry (2016-003321-42); Clinicaltrials.gov registry (NCT03172377); Dutch trial registry (NTRID6417).
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Affiliation(s)
- L J T Smits
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - R W M Pauwels
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - W Kievit
- Department for Health Evidence, Radboudumc, Nijmegen, The Netherlands
| | - D J de Jong
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - A C de Vries
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - F Hoentjen
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - C J van der Woude
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
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9
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Michielsens CAJ, Boers N, den Broeder N, Wenink MH, van der Maas A, Mahler EAM, Mulder MLM, van der Heijde D, van den Hoogen FHJ, Verhoef LM, den Broeder AA. Dose reduction and withdrawal strategy for TNF-inhibitors in psoriatic arthritis and axial spondyloarthritis: design of a pragmatic open-label, randomised, non-inferiority trial. Trials 2020; 21:90. [PMID: 31941544 PMCID: PMC6964104 DOI: 10.1186/s13063-019-4000-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/16/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Tumour necrosis factor inhibitors (TNFi) are effective in the treatment of patients with spondyloarthritis (SpA), including psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA). However, these drugs come with some disadvantages such as adverse events, practical burden for patients and high costs. Dose optimisation of TNFi after patients have reached low disease activity (LDA) has been shown feasible and safe in rheumatoid arthritis (RA). However, data on TNFi dose optimisation in PsA and axSpA are scarce, especially pragmatic, randomised strategy studies. METHODS We developed an investigator-driven, pragmatic, open-label, randomised, controlled, non-inferiority trial (DRESS-PS) to compare the effects of a disease activity-guided treat-to-target strategy with or without a tapering attempt in patients with SpA (PsA and axSpA combined), ≥ 16 years of age, who are being treated with TNFi, and have had at least 6 months of low disease activity. The primary outcome is the percentage of patients in LDA after 12 months of follow up. Patients are assessed at baseline, 3, 6, 9, and 12 months of follow up. Bayesian power analyses with a weakened prior based on a similar study performed in RA resulted in a sample size of 95 patients in total. DISCUSSION More knowledge on disease activity-guided treatment algorithms would contribute to better treatment choices and cost savings and potentially decrease the risk of side effects. In this article we elucidate some of our design choices on TNFi dose optimisation and its clinical and methodological consequences. TRIAL REGISTRATION Dutch Trial Register, NL6771. Registered on 27 November 2018 (CMO NL66181.091.18, 23 October 2018).
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Affiliation(s)
- Celia A J Michielsens
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands. .,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Nadine Boers
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Mark H Wenink
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Elien A M Mahler
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Michelle L M Mulder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands.,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands.,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands.,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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10
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Morita A, Ikumi K. Can the dose and dosing interval of biologics be optimized? Br J Dermatol 2019; 182:264-266. [DOI: 10.1111/bjd.18457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- A. Morita
- Department of Geriatric and Environmental Dermatology Nagoya City University Graduate School of Medical Sciences Mizuho‐cho, Mizuho‐ku Nagoya City Aichi 467‐8601 Japan
| | - K. Ikumi
- Department of Geriatric and Environmental Dermatology Nagoya City University Graduate School of Medical Sciences Mizuho‐cho, Mizuho‐ku Nagoya City Aichi 467‐8601 Japan
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11
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Romero-Jimenez RM, Escudero-Vilaplana V, Baniandres Rodriguez O, García Martín E, Mateos Mayo A, Sanjurjo Saez M. Association between clinical factors and dose modification strategies in the treatment with ustekinumab for moderate-to-severe plaque psoriasis. J DERMATOL TREAT 2018; 29:792-796. [PMID: 29676189 DOI: 10.1080/09546634.2018.1466978] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE The aim of this study was to identify clinical factors associated with dose reduction and dose escalation in the treatment with ustekinumab in patients with moderate-to-severe plaque psoriasis. MATERIALS AND METHODS An observational, longitudinal and retrospective study was conducted using patients with moderate-to-severe plaque psoriasis. We reviewed clinical histories and variables were recorded on a database (patients' characteristics, pharmacotherapeutics, effectiveness and safety). We evaluated correlation between dose reduction, dose escalation and used dose with other variables. RESULTS Of the study's 62 patients, Ustekinumab dose was adjusted in 45.2% (22.6% with reduced doses and 22.6% with increased doses). We found a statistically significant correlation between extending the dosing interval and the absence of psoriatic arthritis, no concomitant systemic therapies, treatment time with ustekinumab, lower PASI at week 28 and achieving PASI75 at week 28. There was also a statistically significant correlation between dose escalation and diabetes mellitus, psoriatic arthritis, prior biological treatments, concomitant systemic therapies, concomitant phototherapy and not achieving PASI75 at week 28. CONCLUSIONS Dose-reduction strategies would increase ustekinumab efficiency in patients that achieve PASI 75 without psoriatic arthritis, diabetes mellitus, previous BT and concomitant treatment with conventional systemic drugs.
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Affiliation(s)
- Rosa M Romero-Jimenez
- a Department of Pharmacy , Hospital General Universitario Gregorio Marañón , Madrid , Spain.,b Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM) , Madrid , Spain
| | - Vicente Escudero-Vilaplana
- a Department of Pharmacy , Hospital General Universitario Gregorio Marañón , Madrid , Spain.,b Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM) , Madrid , Spain
| | - Ofelia Baniandres Rodriguez
- b Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM) , Madrid , Spain.,c Department of Dermatology , Hospital General Universitario Gregorio Marañón , Madrid , Spain
| | - Estela García Martín
- a Department of Pharmacy , Hospital General Universitario Gregorio Marañón , Madrid , Spain.,b Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM) , Madrid , Spain
| | - Ana Mateos Mayo
- b Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM) , Madrid , Spain.,c Department of Dermatology , Hospital General Universitario Gregorio Marañón , Madrid , Spain
| | - Maria Sanjurjo Saez
- a Department of Pharmacy , Hospital General Universitario Gregorio Marañón , Madrid , Spain.,b Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM) , Madrid , Spain
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