1
|
Nagel J, Jönsson G, Nilsson JÅ, Manuswin C, Englund M, Saxne T, Kapetanovic MC. Reduced risk of serious pneumococcal infections up to 10 years after a dose of pneumococcal conjugate vaccine in established arthritis. Vaccine 2023; 41:504-510. [PMID: 36496283 DOI: 10.1016/j.vaccine.2022.11.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/21/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND To examine rates of serious pneumococcal infections up to 10 years after vaccination with 7-valent conjugated pneumococcal vaccine (PCV7) in patients with arthritis compared to non-vaccinated arthritis patients. METHODS In total, 595 adult arthritis patients (rheumatoid arthritis; RA = 342, 80 % women and spondylarthropathy; SpA = 253, 45 % women) received one dose of PCV7. Mean age/disease duration were 62/16 and 51/14 years, respectively. For each patient, 4 matched reference subjects were identified. At vaccination, 420 patients received bDMARDs (anti-TNF = 330, tocilizumab = 15, abatacept = 18, anakinra = 1, rituximab = 56). Methotrexate was given as monotherapy (n = 86) or in combination with bDMARD (n = 220). 89 SpA patients received NSAIDs without DMARD. The Skåne Healthcare Register was searched for ICD-10 diagnostic codes for pneumococcal infections (pneumonia, lower respiratory tract infection, septicemia, meningitis, septic arthritis) between January 2000 and December 2018. Frequency of infections after vs before vaccination were calculated (relative risks). Relative risk ratio (RRR) and relative risk reduction (1-RRR) were calculated comparing patients vs non-vaccinated references. Kaplan-Meier and Cox regression were used to investigate time to first event and predictors of infections. RESULTS Among vaccinated RA and SpA patients, there was a significant relative risk reduction of pneumonia and all serious infections; 53% and 46%, respectively. There was no significant difference in time to first pneumonia or all serious infections after vaccination between patients and references. Higher age, RA diagnosis and concomitant prednisolone were associated with infections. CONCLUSION One dose of pneumococcal conjugate vaccine may decrease risk of serious pneumococcal infection up to 10 years in patients with arthritis receiving immunomodulating treatment.
Collapse
Affiliation(s)
- J Nagel
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden
| | - G Jönsson
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Infection Medicine, Lund, Sweden
| | - J-Å Nilsson
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden
| | - C Manuswin
- Centre of Registers South, Skåne University Hospital, Lund, Sweden
| | - M Englund
- Lund University, Skåne University Hospital, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund, Sweden
| | - T Saxne
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden
| | - M C Kapetanovic
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden.
| |
Collapse
|
2
|
Bröms G, Friedman S, Kim SC, Wood ME, Hernandez-Diaz S, Brill G, Bateman BT, Huybrechts KF, Desai RJ. The Patterns of Use of Medications for Inflammatory Bowel Disease During Pregnancy in the US and Sweden Are Changing. Inflamm Bowel Dis 2021; 27:1427-1434. [PMID: 33751058 DOI: 10.1093/ibd/izaa294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Population-level data spanning different countries describing oral and parenteral treatment in pregnant women with inflammatory bowel disease (IBD) are scarce. We studied treatment with sulfasalazine/5-aminosalicylates, corticosteroids, thiopurines/immunomodulators, and tumor necrosis factor (TNF)-inhibitors in the United States (Optum Clinformatics Data Mart and the Medicaid Analytics Extract [MAX]) and in the Swedish national health registers. METHODS We identified 2975 pregnant women in Optum (2004-2013), 3219 women in MAX (2001-2013), and 1713 women in Sweden (2006-2015) with a recorded diagnosis of IBD. We assessed patterns of use for each drug class according to filled prescriptions, assessing frequency of treatment continuation in those that were treated in the prepregnancy period. RESULTS The proportion of women with Crohn's disease and ulcerative colitis on any treatment during pregnancy was 56.1% and 56.3% in Optum, 47.5% and 49.3% in MAX, and 61.3% and 64.7% in Sweden, respectively, and remained stable over time. Sulfasalazine/5-aminosalicylates was the most commonly used treatment in Crohn's disease, ranging from 25.1% in MAX to 31.8% in Optum, and in ulcerative colitis, ranging from 34.9% in MAX to 53.6% in Sweden. From 2006 to 2012, the TNF-inhibitor use increased from 5.0% to 15.5% in Optum, from 3.6% to 8.5% in MAX, and from 0.7% to 8.3% in Sweden. Continuing TNF-inhibitor treatment throughout pregnancy was more common in Optum (55.8%) and in MAX (43.0%) than in Sweden (11.8%). CONCLUSIONS In this population-based study from 2 countries, the proportion of women with IBD treatment in pregnancy remained relatively constant. TNF-inhibitor use increased substantially in both countries.
Collapse
Affiliation(s)
- Gabriella Bröms
- Centre for Pharmacoepidemiology, Department of Medicine Solna, Karolinska Institutet.,Department of Internal Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Sonia Friedman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mollie E Wood
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Gregory Brill
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Rossides M, Kullberg S, Eklund A, Grunewald J, Arkema EV. Sarcoidosis diagnosis and treatment in Sweden: A register-based assessment of variations by region and calendar period. Respir Med 2020; 161:105846. [DOI: 10.1016/j.rmed.2019.105846] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 10/25/2022]
|
4
|
Tatangelo M, Tomlinson G, Paterson JM, Ahluwalia V, Kopp A, Gomes T, Bansback N, Bombardier C. Association of Patient, Prescriber, and Region With the Initiation of First Prescription of Biologic Disease-Modifying Antirheumatic Drug Among Older Patients With Rheumatoid Arthritis and Identical Health Insurance Coverage. JAMA Netw Open 2019; 2:e1917053. [PMID: 31808927 PMCID: PMC6902765 DOI: 10.1001/jamanetworkopen.2019.17053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Prescribing the first biologic treatment for rheumatoid arthritis (RA) is an important decision for patients, their physicians, and payers, with considerable costs and clinical implications. Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) have known effectiveness and safety profiles and are less expensive; therefore, determining the variables contributing to csDMARD treatment duration is an essential question for patients, physicians, and payers. OBJECTIVES To describe access to the first biologic DMARD prescription in a population of patients with RA and identical comprehensive health insurance coverage in Ontario, Canada, and to explore the associations of patient, prescriber, and geographic region with differences in time to first biologic prescription. DESIGN, SETTING, AND PARTICIPANTS This cohort study of incident patients with RA used administrative data with surveillance and patient-level data collected at yearly intervals. A total of 17 672 patients were included in the study; they were residents of Ontario, Canada, had an incident RA diagnosis at age 67 or older between 2002 and 2015, and received at least 1 csDMARD. Data were analyzed in November 2017. EXPOSURE Patient variables were age, sex, disease duration, socioeconomic status, distance to care, and supply of care in the patient's area of residence. Prescriber covariates were year of graduation, specialty of practice, and supply of rheumatologic care in the patient's geographic region. MAIN OUTCOMES AND MEASURES Time from first csDMARD prescription to receipt of first biologic medication. RESULTS Of 17 672 patients, 11 598 (65.6%) were women, and the mean (SD) age was 75.2 (5.8) years. Characteristics associated with longer time to receipt of a biologic prescription were older age (HR for every 5-year increase, 0.66; 95% CI, 0.62-0.71; P < .001), male sex (HR, 0.76; 95% CI, 0.66-0.89; P < .001), and distance to the nearest rheumatologist (HR per 10-km increase, 0.99; 95% CI, 0.98-0.99; P < .001). Prescribers were primarily rheumatologists (151 of 214 [70.6%]) and primary care physicians (26 of 214 [12.1%]). After adjusting for the number of patients eligible to receive biologic DMARDs, rheumatologists' preferences (ie, yearly prescription rates) for using biologic DMARDs increased over time, from 1.7% in 2001 to 4.9% in 2015. After adjusting for calendar year and patient-, prescriber-, and region-level characteristics, substantial variation between prescribers in rates of prescribing a first biologic DMARD were found (65% variance). CONCLUSIONS AND RELEVANCE This study found variation in time to receipt of first biologic DMARD after prescription of first csDMARD in a population with RA after adjustment for individual-level patient, prescriber, and geographic area covariates, despite identical universal health insurance coverage.
Collapse
Affiliation(s)
- Mark Tatangelo
- University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - George Tomlinson
- University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - J. Michael Paterson
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | | | | | - Tara Gomes
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- St Michael’s Hospital, Toronto, Ontario, Canada
| | - Nick Bansback
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Claire Bombardier
- University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
5
|
Different Policy Measures and Practices between Swedish Counties Influence Market Dynamics: Part 1-Biosimilar and Originator Infliximab in the Hospital Setting. BioDrugs 2019; 33:285-297. [PMID: 30945207 PMCID: PMC6533410 DOI: 10.1007/s40259-019-00345-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Decentralisation of healthcare budgets and issuance of local guidelines means that the use of biosimilars can vary by region within a particular country, for example between the 21 counties of Sweden. Objectives This study aimed to analyse the county-level market dynamics of biosimilar and originator infliximab, which are hospital products, and to examine how local policy measures and practices, in addition to national policy, influenced market dynamics. Methods We first conducted a literature review on (biosimilar) policies in Sweden, then analysed market data provided by IQVIA™ on uptake of originator and biosimilar infliximab within the different counties (Q2 2012 to Q4 2017), including discounts from (tender) contracts. Biosimilar market shares were calculated with volume data (measured as defined daily doses [DDDs]). We then discussed our findings in semi-structured interviews with the national pricing and reimbursement agency, key experts within the county councils of Skåne, Västra Götaland, and Stockholm, and an industry representative. Results Market shares of biosimilar infliximab vary widely between counties (range 18–96% in 2017). The initial uptake of biosimilar infliximab was slow and variable, with abrupt increments in biosimilar market shares coinciding with expiration of contracts for the originator product. Different approaches taken by counties to achieve a low cost per DDD of infliximab were identified, i.e., a rapid switch to the biosimilar (Skåne), a delayed switch to the biosimilar (Stockholm), or no switch to the biosimilar when a favourable price on the originator product could be obtained (Västra Götaland). Quantitative analysis showed that 59% of the variability in biosimilar market shares could be explained by the relative difference in discounted price between the biosimilar and the originator product. In addition, qualitative analysis indicated the presence of key opinion leaders, local guidelines and initiatives, and whose budget it affects as drivers in the decision-making process. Conclusions Variations in the market share of biosimilar infliximab between the Swedish counties is largely explained by the discounted price difference between biosimilar and originator product, and counties used different strategies to leverage such biosimilar competition. Additionally, the presence of key opinion leaders, local guidelines and gainsharing arrangements appeared to play a role in infliximab market dynamics in counties.
Collapse
|
6
|
Malmborg P, Mouratidou N, Sachs MC, Hammar U, Khalili H, Neovius M, Hjern A, Smedby KE, Ekbom A, Askling J, Ludvigsson JF, Olén O. Effects of Childhood-onset Inflammatory Bowel Disease on School Performance: A Nationwide Population-based Cohort Study Using Swedish Health and Educational Registers. Inflamm Bowel Dis 2019; 25:1663-1673. [PMID: 30916332 DOI: 10.1093/ibd/izz040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Childhood-onset inflammatory bowel disease (IBD) might negatively impact academic school performance. We conducted a nationwide study to examine the association between childhood-onset IBD and school results. METHODS Our study population was selected from Swedish health registers. In the National Patient Register (1990 to 2013), we identified 2827 children with IBD: Crohn's disease (CD), n = 1207, and ulcerative colitis (UC), n = 1370. Patients were matched with 10 reference individuals by age, sex, birth year, and place of residence (n = 28,235). Final compulsory school grades (0 to 320 grade points) and qualification for high school (yes or no) were obtained through the National School Register. Regression models controlling for socioeconomic factors were used to analyze the association of IBD with school performance. RESULTS Children with IBD had a lower final grade point average (adjusted mean grade difference [AMGD] -4.9, 95% confidence interval [CI] -7.1 to -2.6) but not a significantly higher risk to not qualify for high school (odds ratio [OR] 1.14, CI 0.99-1.31). The results were similar in children with UC (AMGD -5.5, CI -8.7 to -2.3) and CD (AMGD -4.7, CI -8.2 to -1.2). Underperformance was more common in subsets of IBD children characterized by markers associated with long-standing active disease (eg, >30 inpatient days [AMGD-18.1, CI -25.8 to -10.4]). CONCLUSION Most children with IBD achieve comparable results in the final year of compulsory school as their healthy peers. Care should be improved for the subgroup of children for which IBD has a stronger negative impact on school performance.
Collapse
Affiliation(s)
- Petter Malmborg
- Sachs' Children and Youth Hospital, South General Hospital, Stockholm, Sweden.,Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Natalia Mouratidou
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Michael C Sachs
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ulf Hammar
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hamed Khalili
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Division of Gastroenterology, Massachusetts General Hospital; Harvard Medical School, Boston, Massachusetts, USA
| | - Martin Neovius
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anders Hjern
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Centre for Health Equity Studies, Stockholm University/Karolinska Institutet, Stockholm, Sweden
| | - Karin E Smedby
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anders Ekbom
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johan Askling
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
| | - Ola Olén
- Sachs' Children and Youth Hospital, South General Hospital, Stockholm, Sweden.,Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
7
|
Oldsberg L, Garellick G, Osika Friberg I, Samulowitz A, Rolfson O, Nemes S. Geographical variations in patient-reported outcomes after total hip arthroplasty between 2008 - 2012. BMC Health Serv Res 2019; 19:343. [PMID: 31146790 PMCID: PMC6543668 DOI: 10.1186/s12913-019-4171-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/20/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Health care on equal terms is a cornerstone of the Swedish health care system. Total hip arthroplasty (THA) is considered a success story in Sweden with low frequency of reoperations and restored health-related quality of life (HRQoL). Administratively, health care in Sweden is locally self-governed by 21 counties. In this longitudinal nation-wide observational study we assessed the possible geographical variations in 1-year follow-up patient-reported outcomes (PROs): EQ-5D index, EQ VAS, Pain VAS and Satisfaction VAS. METHODS Study population consisted of 36,235 Swedish THA patients, operated during 2008 to 2012 due to hip osteoarthritis. Individual data came from Swedish Hip Arthroplasty Register, Statistics Sweden and National Board of Health and Welfare. We used descriptive statistics together with multivariable regression analysis to analyse the data. RESULTS We observed county level differences in both preoperative and postoperative PROs. The results showed that the differences observed in preoperative PROs could not fully explain the differences observed in postoperative PROs, even after adjustment for patient demographics (age, sex, BMI, Elixhauser comorbidity index, marital status, educational level and disposable income). This indicates that other factors might influence the outcome after THA. CONCLUSION Likely, structural and process differences such as indication for surgery have an influence on PROs after surgery. Standardization of care at hospital levels may decrease geographical variations in postoperative HRQoL. Remaining differences will then possibly be associated to patient demographics.
Collapse
Affiliation(s)
- Linnea Oldsberg
- Swedish Hip Arthroplasty Register, Gothenburg, Sweden
- Department of Public Health and Community Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Göran Garellick
- Swedish Hip Arthroplasty Register, Gothenburg, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ingrid Osika Friberg
- Department of Public Health and Community Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Equity in Health Care, Region Västra Götaland, Sweden
| | - Anke Samulowitz
- Department of Public Health and Community Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Equity in Health Care, Region Västra Götaland, Sweden
| | - Ola Rolfson
- Swedish Hip Arthroplasty Register, Gothenburg, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Szilárd Nemes
- Swedish Hip Arthroplasty Register, Gothenburg, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
8
|
Baumgart DC, Misery L, Naeyaert S, Taylor PC. Biological Therapies in Immune-Mediated Inflammatory Diseases: Can Biosimilars Reduce Access Inequities? Front Pharmacol 2019; 10:279. [PMID: 30983996 PMCID: PMC6447826 DOI: 10.3389/fphar.2019.00279] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/05/2019] [Indexed: 12/30/2022] Open
Abstract
Biological therapies are an effective treatment for a range of immune-mediated inflammatory diseases (IMIDs), including rheumatoid arthritis, psoriasis, and inflammatory bowel diseases. However, due to their high costs, considerable differences in their utilization exist across the world, even among the various European countries, with many countries restricting access despite professional society guideline recommendations. Adoption of biologics by healthcare providers has been particularly poor in many Central and Eastern European countries. Differences in utilization have also been observed across medical specialties, healthcare providers, and at a regional and national level. The objective of this paper is to provide an overview of the different market access policies for biologics in Europe and to investigate reasons for such differences. One of the potential solutions for providing broader access to IMID patients, where cost is the major barrier, is to encourage the use of biosimilars in place of their reference products. Biosimilars are generally less expensive alternatives to already licensed biological therapies and are approved on the basis that they are similar to the reference product in terms of quality, safety, and efficacy. Budget impact models predict considerable cost savings following the introduction of biosimilars in the next few years. These savings could be used to increase access to biologics and other innovative therapies.
Collapse
Affiliation(s)
- Daniel C. Baumgart
- Inflammatory Bowel Disease Unit – Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
- Department of Gastroenterology and Hepatology, Charité Medical School, Humboldt-University of Berlin, Berlin, Germany
| | - Laurent Misery
- Department of Dermatology, University Hospital of Brest, Brest, France
| | | | - Peter C. Taylor
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
9
|
Fracture Risk in Patients With Inflammatory Bowel Disease: A Nationwide Population-Based Cohort Study From 1964 to 2014. Am J Gastroenterol 2019; 114:291-304. [PMID: 30730858 DOI: 10.14309/ajg.0000000000000062] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Most studies on fractures in inflammatory bowel disease (IBD) are based on patients from tertiary centers or patients followed up before the introduction of immunomodulators or biologics. In addition, the role of corticosteroids in fracture risk has rarely been examined. METHODS We conducted a nationwide population-based cohort study of 83,435 patients with incident IBD (ulcerative colitis [UC]: n = 50,162, Crohn's disease [CD]: n = 26,763, and IBD unclassified: 6,510) and 825,817 reference individuals from 1964 to 2014. Using multivariable Cox regression, we estimated hazard ratios (HRs) for hip fracture and any fracture and the association with cumulative corticosteroid exposure. RESULTS During 1,225,415 person-years of follow-up in patients with IBD, there were 2,491 first-time hip fractures (203/100,000 person-years) compared with 20,583 hip fractures during 12,405,642 person-years in reference individuals (159/100,000 person-years). This corresponded to an HR of 1.42 (95% confidence interval [CI] = 1.36-1.48). The risk for hip fracture was higher in CD compared with UC (P < 0.001). Inflammatory bowel disease was also associated with any fracture (IBD: HR = 1.18; 95% CI = 1.15-1.20). Hazard ratios for hip fracture had not changed since the introduction of immunomodulators or biologics. Increasing exposure to corticosteroids was associated with hip fracture in both IBD and non-IBD individuals (P < 0.001), but only in elderly (>60 years) patients with IBD. The association between IBD and hip fracture was nonsignificant among individuals without corticosteroids (HR = 1.11; 95% CI = 0.86-1.44). CONCLUSIONS Inflammatory bowel disease (CD and UC) is associated with an increased risk of hip fracture and any fracture, but not in individuals without a history of corticosteroid treatment. The association between corticosteroids and hip fracture was restricted to elderly patients with IBD.
Collapse
|
10
|
Weimers P, Halfvarson J, Sachs MC, Saunders-Pullman R, Ludvigsson JF, Peter I, Burisch J, Olén O. Inflammatory Bowel Disease and Parkinson's Disease: A Nationwide Swedish Cohort Study. Inflamm Bowel Dis 2019; 25:111-123. [PMID: 29788069 DOI: 10.1093/ibd/izy190] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few studies have examined the association between inflammatory bowel disease (IBD) and Parkinson's disease (PD). METHODS To estimate the incidence and relative risk of PD development in a cohort of adult IBD, we included all incident IBD patients (n = 39,652) in the Swedish National Patient Register (NPR) between 2002 and 2014 (ulcerative colitis [UC]: n = 24,422; Crohn's disease [CD]: n = 11,418; IBD-unclassified [IBD-U]: n = 3812). Each IBD patient was matched for sex, age, year, and place of residence with up to 10 reference individuals (n = 396,520). In a cohort design, all incident PD occurring after the index date was included from the NPR. In a case-control design, all incident PD occurring before the index date was included. The association between IBD and PD and vice versa was investigated by multivariable Cox and logistic regression. RESULTS In IBD, there were 103 cases of incident PD, resulting in hazard ratios (HRs) for PD of 1.3 (95% confidence interval [CI], 1.0-1.7; P = 0.04) in UC, 1.1 (95% CI, 0.7-1.7) in CD, and 1.7 (95% CI, 0.8-3.0) in IBD-U. However, these effects disappeared when adjusting for number of medical visits during follow-up to minimize potential surveillance bias. In a case-control analysis, IBD patients were more likely to have prevalent PD at the time of IBD diagnosis than matched controls, with odds ratios of 1.4 (95% CI, 1.2-1.8) in all IBD patients, 1.4 (95% CI, 1.1-1.9) for UC, and 1.6 (95% CI, 1.1-2.3) for CD patients alone. CONCLUSIONS IBD is associated with an increased risk of PD, but some of this association might be explained by surveillance bias. 10.1093/ibd/izy190_video1izy190.video15785623138001.
Collapse
Affiliation(s)
- Petra Weimers
- Department of Gastroenterology, North Zealand University Hospital, Frederikssund, Denmark
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Michael C Sachs
- Unit of Biostatistics, Institute of Environmental Medicine, Stockholm, Sweden
| | | | - Jonas F Ludvigsson
- Department Medical Epidemiology and Biostatistics, Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
| | - Inga Peter
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital, Frederikssund, Denmark
| | - Ola Olén
- Clinical Epidemiology Unit, Department of Medicine Solna, Stockholm, Sweden.,Department of Pediatric gastroenterology and nutrition, Sachs' Children and Youth Hospital, Stockholm, Sweden.,Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
11
|
Everhov ÅH, Halfvarson J, Myrelid P, Sachs MC, Nordenvall C, Söderling J, Ekbom A, Neovius M, Ludvigsson JF, Askling J, Olén O. Incidence and Treatment of Patients Diagnosed With Inflammatory Bowel Diseases at 60 Years or Older in Sweden. Gastroenterology 2018; 154:518-528.e15. [PMID: 29102619 DOI: 10.1053/j.gastro.2017.10.034] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 09/12/2017] [Accepted: 10/26/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Diagnosis of inflammatory bowel diseases (IBD) is increasing among elderly persons (60 years or older). We performed a nationwide population-based study to estimate incidence and treatment of IBD. METHODS We identified all incident IBD cases in Sweden from 2006 through 2013 using national registers and up to 10 matched population comparator subjects. We collected data on the patients' health care contacts and estimated incidence rates, health service burden, pharmacologic treatments, extra-intestinal manifestations, and surgeries in relation to age of IBD onset (pediatric, <18 years; adults, 18-59 years; elderly, ≥60 years). RESULTS Of 27,834 persons diagnosed with incident IBD, 6443 (23%) had a first diagnosis of IBD at 60 years or older, corresponding to an incidence rate of 35/100,000 person-years (10/100,000 person-years for Crohn's disease, 19/100,000 person-years for ulcerative colitis, and 5/100,000 person-years for IBD unclassified). During a median follow-up period of 4.2 years (range, 0-9 years), elderly patients had less IBD-specific outpatient health care but more IBD-related hospitalizations and overall health care use than adult patients with IBD. Compared with patients with pediatric or adult-onset IBD, elderly patients used fewer biologics and immunomodulators but more systemic corticosteroids. Occurrence of extra-intestinal manifestations was similar in elderly and adult patients, but bowel surgery was more common in the elderly (13% after 5 years vs 10% in adults) (P < .001). The absolute risk of bowel surgery was higher in the elderly than in the general population, but in relative terms, the risk increase was larger in younger age groups. CONCLUSIONS In a nationwide cohort study in Sweden, we associated diagnosis of IBD at age 60 years or older with a lower use of biologics and immunomodulators but higher absolute risk of bowel surgery, compared with diagnosis at a younger age. The large differences in pharmacologic treatment of adults and elderly patients are not necessarily because of a milder course of disease and warrant further investigation.
Collapse
Affiliation(s)
- Åsa H Everhov
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Pär Myrelid
- Division of Surgery, Department of Clinical and Experimental Medicine, Faulty of Health Sciences, Linköping University and Department of Surgery, County Council of Östergötland Linköping, Sweden
| | - Michael C Sachs
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Caroline Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Söderling
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anders Ekbom
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Martin Neovius
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK; Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Johan Askling
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ola Olén
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Pediatric Gastroenterology and Nutrition, Sachs' Children and Youth Hospital, Stockholm, Sweden
| |
Collapse
|
12
|
Nordenvall C, Rosvall O, Bottai M, Everhov ÅH, Malmborg P, Smedby KE, Ekbom A, Askling J, Ludvigsson JF, Myrelid P, Olén O. Surgical Treatment in Childhood-onset Inflammatory Bowel Disease-A Nationwide Register-based Study of 4695 Incident Patients in Sweden 2002-2014. J Crohns Colitis 2018; 12:157-166. [PMID: 29029152 DOI: 10.1093/ecco-jcc/jjx132] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/19/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS The incidence of childhood-onset [< 18 years] inflammatory bowel disease [IBD] is increasing worldwide, and some studies suggest that it represents a more severe disease phenotype. Few nationwide, population-based studies have evaluated the surgical burden in patients with childhood-onset IBD, and whether the improved medical treatment has influenced the need for gastrointestinal surgery. The aim was to examine whether the surgical treatment at any age of patients with childhood-onset IBD has changed over time. METHODS In a nationwide cohort study we identified 4695 children [< 18 years] diagnosed with incident IBD in 2002-2014 through the Swedish Patient Register [ulcerative colitis: n = 2295; Crohn's disease: n = 2174; inflammatory bowel disease-unclassified: n = 226]. Abdominal [intestinal resections and colectomies] and perianal surgeries were identified through the Swedish Patient Register. The cumulative incidences of surgeries were calculated using the Kaplan-Meier method. RESULTS In the cohort, 44% were females and 56% males. The median age at inflammatory bowel disease diagnosis was 15 years and the maximum age at end of follow-up was 31 years. The 3-year cumulative incidence of intestinal surgery was 5% in patients with ulcerative colitis and 7% in patients with Crohn's disease, and lower in children aged < 6 years at inflammatory bowel disease diagnosis [3%] than in those aged 15-17 years at diagnosis [7%]. Calendar period of inflammatory bowel disease diagnosis was not associated with risk of surgery. CONCLUSION Over the past 13 years, the risk of surgery in childhood-onset inflammatory bowel disease has remained unchanged.
Collapse
Affiliation(s)
- Caroline Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Center for Digestive Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Oda Rosvall
- Department of Clinical and Experimental Medicine, Linköping University, and Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - Matteo Bottai
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Åsa H Everhov
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Petter Malmborg
- Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Karin E Smedby
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anders Ekbom
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johan Askling
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, Örebro, Sweden.,Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK.,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, and Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - Ola Olén
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden
| |
Collapse
|
13
|
Olén O, Askling J, Sachs MC, Frumento P, Neovius M, Smedby KE, Ekbom A, Malmborg P, Ludvigsson JF. Childhood onset inflammatory bowel disease and risk of cancer: a Swedish nationwide cohort study 1964-2014. BMJ 2017; 358:j3951. [PMID: 28931512 PMCID: PMC5605779 DOI: 10.1136/bmj.j3951] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective To assess risk of cancer in patients with childhood onset inflammatory bowel disease in childhood and adulthood.Design Cohort study with matched general population reference individuals using multivariable Cox regression to estimate hazard ratios.Setting Swedish national patient register (both inpatient and non-primary outpatient care) 1964-2014.Participants Incident cases of childhood onset (<18 years) inflammatory bowel disease (n=9405: ulcerative colitis, n=4648; Crohn's disease, n=3768; unclassified, n=989) compared with 92 870 comparators from the general population matched for sex, age, birth year, and county.Main outcome measures Any cancer and cancer types according to the Swedish Cancer Register.Results During follow-up through adulthood (median age at end of follow-up 27 years), 497 (3.3 per 1000 person years) people with childhood onset inflammatory bowel disease had first cancers, compared with 2256 (1.5 per 1000 person years) in the general population comparators (hazard ratio 2.2, 95% confidence interval 2.0 to 2.5). Hazard ratios for any cancer were 2.6 in ulcerative colitis (2.3 to 3.0) and 1.7 in Crohn's disease (1.5 to 2.1). Patients also had an increased risk of cancer before their 18th birthday (2.7, 1.6 to 4.4; 20 cancers in 9405 patients, 0.6 per1000 person years). Gastrointestinal cancers had the highest relative risks, with a hazard ratio of 18.0 (14.4 to 22.7) corresponding to 202 cancers in patients with inflammatory bowel disease. The increased risk of cancer (before 25th birthday) was similar over time (1964-1989: 1.6, 1.0 to 2.4; 1990-2001: 2.3, 1.5 to 3.3); 2002-06: 2.9, 1.9 to 4.2; 2007-14: 2.2, 1.1 to 4.2).Conclusion Childhood onset inflammatory bowel disease is associated with an increased risk of any cancer, especially gastrointestinal cancers, both in childhood and later in life. The higher risk of cancer has not fallen over time.
Collapse
Affiliation(s)
- O Olén
- Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - J Askling
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - M C Sachs
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - P Frumento
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - M Neovius
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - K E Smedby
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - A Ekbom
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - P Malmborg
- Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden
- Department of Women's and Children's health, Karolinska Institutet, Stockholm, Sweden
| | - J F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
- Department of Pediatrics, Orebro University Hospital, Orebro, Sweden
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, UK
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| |
Collapse
|
14
|
Eberhardson M, Söderling JK, Neovius M, Cars T, Myrelid P, Ludvigsson JF, Askling J, Ekbom A, Olén O. Anti-TNF treatment in Crohn's disease and risk of bowel resection-a population based cohort study. Aliment Pharmacol Ther 2017; 46:589-598. [PMID: 28752637 DOI: 10.1111/apt.14224] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/16/2017] [Accepted: 06/23/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND TNF inhibitors (TNFi) have been shown to reduce the need for surgery in Crohn's disease, but few studies have examined their effect beyond the first year of treatment. AIM To conduct a register-based observational cohort study in Sweden 2006-2014 to investigate the risk of bowel resection in bowel surgery naïve TNFi-treated Crohn's disease patients and whether patients on TNFi ≥12 months are less likely to undergo bowel resection than patients discontinuing treatment before 12 months. METHODS We identified all individuals in Sweden with Crohn's disease through the Swedish National Patient Register 1987-2014 and evaluated the incidence of bowel resection after first ever dispensation of adalimumab or infliximab from 2006 and up to 7 years follow-up. RESULTS We identified 1856 Crohn's disease patients who had received TNFi. Among these patients, 90% treatment retention was observed at 6 months after start of TNFi and 65% remained on the drug after 12 months. The cumulative rates of surgery in Crohn's disease patients exposed to TNFi years 1-7 were 7%, 13%, 17%, 20%, 23%, 25% and 28%. Rates of bowel resection were similar between patients with TNFi survival <12 months and ≥12 months respectively (P=.27). No predictors (eg, sex, age, extension or duration of disease) for bowel resection were identified. CONCLUSIONS The risk of bowel resection after start of anti-TNF treatment is higher in regular health care than in published RCTs. Patients on sustained TNFi treatment beyond 12 months have bowel resection rates similar to those who discontinue TNFi treatment earlier.
Collapse
Affiliation(s)
- M Eberhardson
- Danderyd's Hospital, Stockholm, Sweden.,Karolinska Institutet, Stockholm, Sweden
| | | | - M Neovius
- Karolinska Institutet, Stockholm, Sweden
| | - T Cars
- Public Healthcare Service, Stockholm, Sweden.,Uppsala University, Uppsala, Sweden
| | - P Myrelid
- Linköping University, Linköping, Sweden.,County Council of Östergötland, Linköping, Sweden
| | - J F Ludvigsson
- Karolinska Institutet, Stockholm, Sweden.,Örebro University Hospital, Örebro, Sweden
| | - J Askling
- Karolinska Institutet, Stockholm, Sweden
| | - A Ekbom
- Karolinska Institutet, Stockholm, Sweden
| | - O Olén
- Karolinska Institutet, Stockholm, Sweden.,Sachs' Children's Hospital, Stockholm, Sweden
| |
Collapse
|
15
|
Use of bisphosphonate might be important to improve bone mineral density in patients with rheumatoid arthritis even under tight control: the TOMORROW study. Rheumatol Int 2017; 37:999-1005. [PMID: 28405825 DOI: 10.1007/s00296-017-3720-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 04/07/2017] [Indexed: 10/19/2022]
Abstract
Although patients with rheumatoid arthritis (RA) are prone to osteoporosis, tight control of disease activity might have a positive effect on bone metabolism. We aimed to determine whether bisphosphonate use is still important to improve bone mineral density (BMD) in RA patients whose disease activity was tightly controlled and the dose of glucocorticoid was reduced. This study was a sub-analysis of the 10-year prospective cohort TOtal Management Of Risk factors in Rheumatoid arthritis patients to lOWer morbidity and mortality: the TOMORROW which started from 2010. We compared BMD between 192 patients with RA and age- and sex-matched volunteers between 2010 and 2013 using dual-energy X-ray absorptiometry (DXA) in whole body mode. We then determined ratios of changes in BMD (%ΔBMD) to assess factors influencing increases in BMD among the patients using multivariate logistic regression analysis. The BMD was significantly lower in the patients than in the controls at all sites surveyed during 2010 and 2013. The %ΔBMD of the total spine was significantly higher among the patients treated with, than without bisphosphonate (6.2 vs. 1.8%, P = 0.0001). Multivariate logistic regression analysis revealed that use of bisphosphonate was a significant factor contributing to BMD increase (odds ratio 2.13; 95% confidence interval, 1.03-4.38, P = 0.041). Meanwhile, use of biologic agents, reducing glucocorticoid dose, and control of disease activity were not significant factors for gain of BMD. The BMD was lower among patients with RA than non-RA controls. Use of bisphosphonate significantly increased the BMD of the spine in patients over a period of 3 years and was important for maintaining the BMD among patients with RA under the control of inflammation and disease activity.
Collapse
|
16
|
Calara PS, Althin R, Carlsson KS, Schmitt-Egenolf M. Regional Differences in the Prescription of Biologics for Psoriasis in Sweden: A Register-Based Study of 4168 Patients. BioDrugs 2017; 31:75-82. [PMID: 28097638 PMCID: PMC5258782 DOI: 10.1007/s40259-016-0209-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Observational studies suggest an inequitable prescription of biologics in psoriasis care, which may be attributed to geographical differences in treatment access. Sweden regularly ranks high in international comparisons of equitable healthcare, and is, in connection with established national registries, an ideal country to investigate potential inequitable access. OBJECTIVE The aim was to determine whether the opportunity for patients to receive biologics depends on where they receive care. METHODS Biologic-naïve patients enrolled in the Swedish National Register for Systemic Treatment of Psoriasis (PsoReg) from 2008 to 2015 (n = 4168) were included. The association between the likelihood of initiating a biologic and the region where patients received care was analyzed. The strength of the association was adjusted for patient and clinical characteristics, as well as disease severity using logistic regression analysis. The proportion of patients that switched to a biologic (switch rate) and the probability of switch to a biologic was calculated in 2-year periods. RESULTS The national switch rate increased marginally over time from 9.7 to 11.0%, though the uptake varied across regions. Adjusted odds ratios for at least one region were significantly different from the reference region in every 2-year period. During the latest period (2014-2015), the average patient in the lowest prescribing region was nearly 2.5 times less likely to switch as a similar patient in the highest prescribing region. CONCLUSIONS Geographical differences in biologics prescription persist after adjusting for patient characteristics and disease severity. The Swedish example calls for further improvements in delivering equitable psoriasis care.
Collapse
Affiliation(s)
- Paul S Calara
- The Swedish Institute for Health Economics (IHE), Lund, Sweden
| | - Rikard Althin
- The Swedish Institute for Health Economics (IHE), Lund, Sweden
| | - Katarina Steen Carlsson
- The Swedish Institute for Health Economics (IHE), Lund, Sweden
- Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
| | - Marcus Schmitt-Egenolf
- Department of Public Health and Clinical Medicine, Dermatology, Umeå University, 901 87, Umeå, Sweden.
| |
Collapse
|
17
|
Ludvigsson JF, Büsch K, Olén O, Askling J, Smedby KE, Ekbom A, Lindberg E, Neovius M. Prevalence of paediatric inflammatory bowel disease in Sweden: a nationwide population-based register study. BMC Gastroenterol 2017; 17:23. [PMID: 28143594 PMCID: PMC5282815 DOI: 10.1186/s12876-017-0578-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 01/18/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND We evaluated the impact of different case definition algorithms on the prevalence of paediatric inflammatory bowel disease (IBD), Crohn's disease (CD) and ulcerative colitis (UC) and to compare the occurrence of certain diseases compared to matched controls. METHODS Paediatric patients (<18 years) were identified via ICD codes for UC and CD in Swedish registers between 1993 and 2010 (n = 1432). Prevalence was defined as ≥2 IBD-related visits. Prevalence of treated children in 2010 was defined as ≥2 IBD-related visits with one visit and ≥1 dispensed IBD-related drug prescription in 2010. To test the robustness of the estimates, prevalence was also calculated according to alternative case definitions. The presence of rheumatic, hepatobiliary, pancreatic, and dermatologic diseases were compared with age-/sex-/county-of-residence-matched general population controls. RESULTS The IBD prevalence was 75/100,000 (CD: 29/100,000; UC: 30/100,000; patients with IBD-U: 16/100,000). Prevalence of treated disease in 2010 was 62/100,000 (CD: 23/100,000; UC: 25/100,000; patients with IBD-U: 13/100,000). When age restrictions were employed, the prevalence estimate decreased (<17y: 61/100,000, <16y: 49/100,000 and <15y: 38/100,000). Compared to general population controls (n = 8583), children with IBD had a higher prevalence of dermatologic (4.7% vs. 0.6%), hepatobiliary (including primary sclerosing cholangitis) (5.5% vs. 0.1%), pancreatic (1.7% vs. 0%) and rheumatic diseases (7.2% vs. 1.2%; all P < 0.01). CONCLUSIONS The overall prevalence of paediatric IBD in Sweden was similar to that in earlier regional cohorts. IBD patients had a higher prevalence of comorbid conditions than matched general population controls.
Collapse
Affiliation(s)
- J F Ludvigsson
- Department of Paediatrics, Örebro University Hospital, Örebro, Sweden. .,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, SE-171 76, Stockholm, Sweden.
| | - K Büsch
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - O Olén
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden.,Department of paediatric gastroenterology and nutrition, Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - J Askling
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden.,Department of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - K E Smedby
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - A Ekbom
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - E Lindberg
- Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
| | - M Neovius
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
18
|
Svedbom A, Dalén J, Black CM, Kachroo S. Persistence and costs with subcutaneous TNF-alpha inhibitors in immune-mediated rheumatic disease stratified by treatment line. Patient Prefer Adherence 2017; 11:95-106. [PMID: 28144130 PMCID: PMC5248937 DOI: 10.2147/ppa.s119808] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The objectives of this study were to 1) describe and compare treatment persistence with first- and second-line subcutaneous tumor necrosis factor-alpha inhibitors (SC-TNFis) in patients with ankylosing spondylitis (AS), psoriatic arthritis (PsA), or rheumatoid arthritis (RA) (collectively immune-mediated rheumatic disease) in Sweden and 2) estimate and contrast health care costs in the two groups. METHODS Patients who initiated their first or second SC-TNFi between May 6 2010 and December 12 2012 were identified from the Prescribed Drug Register. Persistence was estimated using survival analysis. Costs comprised specialized outpatient care, inpatient care, and medication. The persistence analysis was stratified by immune-mediated rheumatic disease diagnosis. RESULTS A total of 4,903 patients treated with their first and 845 patients treated with their second SC-TNFi were identified. Baseline characteristics differed between the two groups. Therefore, propensity score matching analysis was implemented. Second-line patients were matched to first-line patients, and four cohort pairs (AS, PsA, RA, and all diagnoses combined) were generated. Patients treated with their first SC-TNFi had statistically significant higher persistence than patients treated with their second SC-TNFi in PsA (P=0.036), RA (P=0.048), and all diagnoses combined (P<0.001) but not in AS (P=0.741). Patients who were treated with their second SC-TNFi incurred higher costs than patients treated with their first SC-TNFi. CONCLUSION Overall, persistence to the first SC-TNFi was higher than persistence to the second SC-TNFi. Furthermore, the second SC-TNFi was associated with higher costs than the first SC-TNFi. Therefore, prescribing the SC-TNFi with the best long-term persistence first may be beneficial.
Collapse
Affiliation(s)
| | | | | | - Sumesh Kachroo
- Merck & Co., Inc., Kenilworth, NJ, USA
- Correspondence: Sumesh Kachroo, Merck & Co., Inc., 126 E. Lincoln Avenue, Rahway, NJ 07065, USA, Tel +1 732 594 3847, Fax +1 732 594 4910, Email
| |
Collapse
|
19
|
Healthcare Provider Type and Switch to Biologics in Psoriasis: Evidence from Real-World Practice. BioDrugs 2016; 30:145-51. [PMID: 26883786 DOI: 10.1007/s40259-016-0163-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous research indicates an uneven uptake of biologics in patients with moderate-to-severe psoriasis in Sweden. Therefore, it is essential to scrutinise variations in treatment patterns. OBJECTIVE The aim of this study was to evaluate the extent to which the uptake of biologics for psoriasis differs between types of healthcare provider. METHODS Three types of provider were identified within 52 units participating in the Swedish National Registry for Systemic Psoriasis Treatment (PsoReg): university hospitals, non-university hospitals and individual practices. Biologics-naïve patients (n = 3165) were included in analyses to investigate the probability of switch to biologics. The numbers of patients fulfilling the criteria for moderate-to-severe psoriasis [Psoriasis Area and Severity Index (PASI) ≥10 and Dermatology Life Quality Index (DLQI) ≥10] among patients who switched to biologics and patients who did not switch were reported. A logistic regression model was used to calculate how healthcare provider type influenced the probability of switch to biologics whilst adjusting for patient characteristics and disease severity. RESULTS During registration, 16% of patients switched to biologics while 84% remained on conventional systemic treatment. In 7% of patients, the criteria PASI ≥10 and DLQI ≥10 was fulfilled at their last visit without switching to biologics, whereas in 10% of patients the criteria was not fulfilled prior to switch. After controlling for patient characteristics and disease severity, small or no difference in the probability of switch was observed between provider types. CONCLUSIONS Disease severity does not explain the decision to switch or not to switch to biologics for a disproportionate number of patients. There seems to be an uneven uptake of biologics in Swedish clinical practice, but the type of healthcare provider cannot explain this variation. More research is needed on what factors influence the prescription of biologics.
Collapse
|
20
|
Putrik P, Ramiro S, Lie E, Keszei AP, Kvien TK, van der Heijde D, Landewé R, Uhlig T, Boonen A. Less educated and older patients have reduced access to biologic DMARDs even in a country with highly developed social welfare (Norway): results from Norwegian cohort study NOR-DMARD. Rheumatology (Oxford) 2016; 55:1217-24. [PMID: 27012686 DOI: 10.1093/rheumatology/kew048] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To explore whether age, gender or education influence the time until initiation of the first bDMARD in patients with RA. METHODS Data from the Norwegian Register of DMARDs collected between 2000 and 2012 were used. Only DMARD-naïve patients with RA starting their first conventional synthetic DMARD were included in the analyses. The start of the first bDMARD was the main outcome of interest. Cox regression analyses were used to explore the impact of education, age and gender on the start of a first bDMARD, adjusting for confounders, either at baseline or varying over time (time-varying model). RESULTS Of 1946 eligible patients [mean (s.d.) age: 55 (14) years, 68% females], 368 (19%) received a bDMARD during follow-up (mean 2.6 years). In the baseline prediction model, older age [Hazard Ratio (HR) 0.97, 95% CI: 0.96, 0.98], lower education [HR = 0.76 and 0.68 for low and intermediate education levels vs college/university education, respectively (P = 0.01)] and female gender [only in the period 2000-03, HR = 0.61 (95% CI: 0.41, 0.91)] were associated with a lower hazard ratio to start a bDMARD. The time-varying model provided overall consistent results, but the effect of education was only relevant for older patients (>57 years) and became more pronounced by the end of the decade. CONCLUSIONS Less educated and older patients have disadvantages with regard to access to costly treatments, even in a country with highly developed welfare like Norway. Females had lower access in the beginning of the 2000s, but access had improved by the end of the decade.
Collapse
Affiliation(s)
- Polina Putrik
- Rheumatology, Maastricht University Medical Center and CAPHRI Research Institute Maastricht University Health Promotion and Education, Maastricht University, Maastricht
| | - Sofia Ramiro
- Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Andras P Keszei
- Medical Informatics, Uniklinik RWTH Aachen University, Aachen, Germany
| | - Tore K Kvien
- Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Désirée van der Heijde
- Rheumatology, Leiden University Medical Center, Leiden, the Netherlands Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Robert Landewé
- Amsterdam Rheumatology & Immunology Center, Amsterdam, Amsterdam Rheumatology, Atrium Medical Center, Heerlen, the Netherlands and
| | - Till Uhlig
- Rheumatology, Maastricht University Medical Center and CAPHRI Research Institute Maastricht University Rheumatology, Diakonhjemmet Hospital, National Advisory Unit on Rehabilitation in Rheumatology, Oslo, Norway
| | - Annelies Boonen
- Rheumatology, Maastricht University Medical Center and CAPHRI Research Institute Maastricht University
| |
Collapse
|
21
|
Tada M, Inui K, Sugioka Y, Mamoto K, Okano T, Koike T, Nakamura H. Reducing glucocorticoid dosage improves serum osteocalcin in patients with rheumatoid arthritis-results from the TOMORROW study. Osteoporos Int 2016; 27:729-35. [PMID: 26294294 DOI: 10.1007/s00198-015-3291-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 08/11/2015] [Indexed: 01/30/2023]
Abstract
UNLABELLED Decreasing the daily dose of glucocorticoids improved bone metabolic marker levels in patients with rheumatoid arthritis. However, changes in disease activity did not influence bone metabolism. Bone metabolism might thus remain uncontrolled even if disease activity is under good control. Decreasing glucocorticoid dosage appears important for improving bone metabolism. INTRODUCTION Patients with rheumatoid arthritis (RA) develop osteoporosis more frequently than healthy individuals. Bone resorption is increased and bone formation is inhibited in patients with RA, and glucocorticoid negatively affects bone metabolism. We aimed to investigate factors influencing bone metabolic markers in patients with RA. METHODS We started the 10-year prospective cohort Total Management of Risk Factors in Rheumatoid Arthritis Patients to Lower Morbidity and Mortality (TOMORROW) study in 2010. We compared changes in urinary cross-linked N-telopeptide of type I collagen (uNTx) and serum osteocalcin (OC), as markers of bone resorption and formation, respectively, in 202 RA patients and age- and sex-matched volunteers between 2010 and 2011. We also investigated factors influencing ΔuNTx and ΔOC in the RA group using multivariate analysis. RESULTS Values of ΔuNTx were significantly lower in patients with RA than in healthy controls (-0.51 vs. 7.41 nmol bone collagen equivalents (BCE)/mmol creatinine (Cr); p = 0.0013), whereas ΔOC values were significantly higher in RA patients (0.94 vs. 0.37 ng/ml; p = 0.0065). Changes in prednisolone dosage correlated negatively with ΔOC (β = -0.229, p = 0.001), whereas changes in disease activity score, bisphosphonate therapy, and period of biologics therapy did not correlate significantly with ΔOC. No significant correlation was seen between ΔuNTx and change in prednisolone dosage. CONCLUSIONS Decreased glucocorticoid dosage improved bone metabolic markers in RA, but disease activity, bisphosphonate therapy, and period of biologics therapy did not influence levels of bone metabolic markers. Decreasing glucocorticoid dosage appears important for improving bone metabolic marker profiles in patients with RA.
Collapse
Affiliation(s)
- M Tada
- Department of Orthopaedic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - K Inui
- Department of Rheumatosurgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Y Sugioka
- Center for Senile Degenerative Disorders, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - K Mamoto
- Department of Orthopaedic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - T Okano
- Department of Orthopaedic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - T Koike
- Center for Senile Degenerative Disorders, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan.
- Search Institute for Bone and Arthritis Disease, Shirahama Foundation for Health and Welfare, Nishimurogun Shirahamacho 1447, Wakayama, 649-2211, Japan.
| | - H Nakamura
- Department of Orthopaedic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| |
Collapse
|
22
|
Lee RA, Eisen DB. Treatment of hidradenitis suppurativa with biologic medications. J Am Acad Dermatol 2016; 73:S82-8. [PMID: 26470624 DOI: 10.1016/j.jaad.2015.07.053] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 07/16/2015] [Indexed: 11/20/2022]
Abstract
Given the absence of significant improvement in the treatment of hidradenitis suppurativa (HS) with traditional medical and surgical therapies, biologics have piqued the interest of research investigators. The efficacy of biologics in the treatment of inflammatory conditions like psoriasis and rheumatoid arthritis is well-documented. More recently, success with biologics has been demonstrated in atopic dermatitis, another dermatological condition associated with inflammatory states. Researchers have begun to probe the utility of biologic agents in less prevalent conditions that feature inflammation as a key characteristic, namely, hidradenitis suppurativa. Five agents in particular adalimumab, anakinra, etanercept, infliximab, and ustekinumab, have been explored in the setting of HS. Results to date put forward adalimumab and infliximab as biologic treatments that can safely be initiated with some expectant efficacy. Other biologic agents require more rigorous examination before they are worthy of addition to the treatment armamentarium.
Collapse
Affiliation(s)
- Robert A Lee
- Dermatology Clinic, University of California San Diego, San Diego, California.
| | - Daniel B Eisen
- Department of Dermatology, University of California Davis, Sacramento, California
| |
Collapse
|
23
|
Nagel J, Geborek P, Saxne T, Jönsson G, Englund M, Petersson IF, Nilsson JÅ, Kapetanovic MC. The risk of pneumococcal infections after immunization with pneumococcal conjugate vaccine compared to non-vaccinated inflammatory arthritis patients. Scand J Rheumatol 2015; 44:271-9. [PMID: 25656734 DOI: 10.3109/03009742.2014.984754] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To examine the risk of putative pneumococcal infections in adult arthritis patients on different anti-rheumatic drugs immunized with heptavalent pneumococcal conjugate vaccine (Prevenar 7; PCV7) and non-vaccinated individually matched arthritis patients. METHOD All individuals in a cohort of 505 patients with rheumatoid arthritis (RA) or spondylarthropathy (SpA) receiving different anti-rheumatic treatments were immunized with a single dose of PCV7 (exposed group). Of these, 497 patients (RA = 248; SpA = 249) were included. For each vaccinated patient, we identified four reference subjects (n = 1988) from the same geographic area, individually matched for age, gender, and diagnosis. These were considered unexposed to conjugated pneumococcal vaccination. The Skåne Healthcare Register (SHR) was searched for all individuals seeking health care for putative pneumococcal infections occurring 4 years before vaccination and up to 4.5 years after vaccination using ICD-10 diagnostic codes. The following infections were considered as serious cases: pneumonia, other lower respiratory infections, meningitis, sepsis, and septic arthritis. The relative risk (RR) of infection was calculated as the number of events after/number of events before vaccination. Ratios of relative risk (RRRs) were calculated between vaccinated and non-vaccinated groups of patients. A generalized estimating equation (GEE) was used to handle correlated data for several events in the same individual. RESULTS Although statistically non-significant, the point estimate of the RRR [0.55, 95% confidence interval (CI) 0.25-1.22] suggested a reduced risk of serious pneumococcal infections in vaccinated patients compared to the unexposed group. CONCLUSIONS Vaccination with PCV7 tended to reduce the risk of putative serious pneumococcal infections by about 45% compared to non-vaccinated patients in this observational cohort study.
Collapse
Affiliation(s)
- J Nagel
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University and Skåne University Hospital , Sweden
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Waldenlind K, Eriksson JK, Grewin B, Askling J. Validation of the rheumatoid arthritis diagnosis in the Swedish National Patient Register: a cohort study from Stockholm County. BMC Musculoskelet Disord 2014; 15:432. [PMID: 25510838 PMCID: PMC4302140 DOI: 10.1186/1471-2474-15-432] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 12/08/2014] [Indexed: 12/16/2022] Open
Abstract
Background The Swedish National Patient Register offers unique possibilities for identification of large cohorts, such as patients with rheumatoid arthritis (RA). Although the overall diagnostic validity in the register has been reported as good, the aims of this study were to a) specifically validate the RA diagnosis from contemporary outpatient specialist care in this register, and b) assess the proportion of patients identified via algorithms to define incident RA in the register who in clinical practice also have new-onset disease. Methods 211 individuals with prevalent or incident RA in the National Patient Register were included. By extracting diagnosis-related parameters from their medical records, we determined if the patient fulfilled the 2010 ACR/EULAR- and the 1987 ACR-classification criteria for RA. We also determined whether clinical diagnosis was synchronous with disease onset as defined through register-based algorithms. Results For 91% of the prevalent patients, the RA diagnosis in the National Patient Register fulfilled classification criteria or clinical diagnosis for RA. Among individuals identified with incident RA using a strict algorithm for new-onset disease, the RA diagnosis was substantiated in 91%, of whom 92% also represented new-onset disease. Conclusions The validity of the RA diagnosis in the National Patient Register was high and, by using specific algorithms, new-onset RA can be defined. These findings strengthen the notion that the National Patient Register may be used to define RA populations with high validity to allow for high-quality epidemiological studies. Electronic supplementary material The online version of this article (doi:10.1186/1471-2474-15-432) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Kristin Waldenlind
- Department of Rheumatology, Karolinska University Hospital, Stockholm, Sweden.
| | | | | | | |
Collapse
|
25
|
Wadström H, Eriksson JK, Neovius M, Askling J. How good is the coverage and how accurate are exposure data in the Swedish Biologics Register (ARTIS)? Scand J Rheumatol 2014; 44:22-8. [PMID: 25379815 DOI: 10.3109/03009742.2014.927918] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To assess the coverage of the Swedish Biologics Register (Anti-Rheumatic Therapy in Sweden, ARTIS) across indications, and the accuracy of the registered information on treatment with biologics. METHOD Through cross-reference of ARTIS to almost complete national health registers on prescriptions (adalimumab and etanercept), outpatient visits, and death/residency during 2008-2010, we assessed: the treatment coverage of ARTIS for each treatment indication, the validity of the registered start and stop dates, ARTIS treatments with no corresponding drug dispensations, and the accuracy of the registered information on concomitant anti-rheumatic therapies. RESULTS According to the national health registers, 3945 individuals with a spondyloarthropathy (SpA) and 8032 patients with rheumatoid arthritis (RA) had filled at least one adalimumab or etanercept prescription during the study period. Of these, 86% of those with SpAs and 95% of patients with RA were also found in ARTIS with the corresponding treatment. Tumour necrosis factor (TNF) inhibitor prescriptions had been filled by 95% of patients between the ARTIS start and stop dates (allowing a 90-day window). More than 60 days before and more than 60 days after the registered start date in ARTIS, 5% and 4% respectively of patients had filled their first TNF inhibitor prescription. More than 90 days after the registered stop date in ARTIS, 8% of patients had filled one or more TNF inhibitor prescriptions. CONCLUSIONS We observed a high coverage and accuracy of ARTIS data on biologics exposure, for both SpAs and RA. The combination of data from clinical registers such as ARTIS with data from national health registers offers a high quality measurement of actual treatment.
Collapse
Affiliation(s)
- H Wadström
- Clinical Epidemiology Unit, Karolinska Institutet , Stockholm , Sweden
| | | | | | | | | |
Collapse
|
26
|
Campbell SM, Godman B, Diogene E, Fürst J, Gustafsson LL, MacBride-Stewart S, Malmström RE, Pedersen H, Selke G, Vlahović-Palčevski V, van Woerkom M, Wong-Rieger D, Wettermark B. Quality indicators as a tool in improving the introduction of new medicines. Basic Clin Pharmacol Toxicol 2014; 116:146-57. [PMID: 25052464 DOI: 10.1111/bcpt.12295] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 07/07/2014] [Indexed: 01/18/2023]
Abstract
Quality indicators are increasingly used as a tool to achieve safe and quality clinical care, cost-effective therapy, for professional learning, remuneration, accreditation and financial incentives. A substantial number focus on drug therapy but few address the introduction of new medicines even though this is a burning issue. The objective was to describe the issues and challenges in designing and implementing a transparent indicator framework and evaluation protocol for the introduction of new medicines and to provide guidance on how to apply quality indicators in the managed entry of new medicines. Quality indicators need to be developed early to assess whether new medicines are introduced appropriately. A number of key factors need to be addressed when developing, applying and evaluating indicators including dimensions of quality, suggested testing protocols, potential data sources, key implementation factors such as intended and unintended consequences, budget impact and cost-effectiveness, assuring the involvement of the medical professions, patients and the public, and reliable and easy-to-use computerized tools for data collection and management. Transparent approaches include the need for any quality indicators developed to handle conflict of interests to enhance their validity and acceptance. The suggested framework and indicator testing protocol may be useful in assessing the applicability of indicators for new medicines and may be adapted to healthcare settings worldwide. The suggestions build on existing literature to create a field testing methodology that can be used to produce country-specific quality indicators for new medicines as well as a cross international approach to facilitate access to new medicines.
Collapse
Affiliation(s)
- Stephen M Campbell
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK; NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health, University of Manchester, Manchester, UK
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Eriksson JK, Karlsson JA, Bratt J, Petersson IF, van Vollenhoven RF, Ernestam S, Geborek P, Neovius M. Cost-effectiveness of infliximab versus conventional combination treatment in methotrexate-refractory early rheumatoid arthritis: 2-year results of the register-enriched randomised controlled SWEFOT trial. Ann Rheum Dis 2014; 74:1094-101. [PMID: 24737786 PMCID: PMC4431324 DOI: 10.1136/annrheumdis-2013-205060] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 03/23/2014] [Indexed: 11/04/2022]
Abstract
Objective To estimate the incremental cost-effectiveness of infliximab versus conventional combination treatment over 21 months in patients with methotrexate-refractory early rheumatoid arthritis. Methods In this multicentre, two-arm, parallel, randomised, active-controlled, open-label trial, rheumatoid arthritis patients with <1 year symptom duration were recruited from 15 rheumatology clinics in Sweden between October 2002 and December 2005. After 3–4 months of methotrexate monotherapy, patients not achieving low disease activity were randomised to addition of infliximab or sulfasalazine+hydroxychloroquine (conventional treatment group). Costs of drugs, healthcare use, and productivity losses were retrieved from nationwide registers, while EuroQol 5-Dimensions utility was collected quarterly. Results Of 487 patients initially enrolled, 128 and 130 were randomised to infliximab and conventional treatment, respectively. The infliximab group accumulated higher drug and healthcare costs (€27 487 vs €10 364; adjusted mean difference €16 956 (95% CI 14 647 to 19 162)), while productivity losses did not differ (€33 804 vs €29 220; €3961 (95% CI −3986 to 11 850)), resulting in higher societal cost compared to the conventional group (€61 291 vs €39 584; €20 916 (95% CI 12 800 to 28 660)). Mean accumulated quality-adjusted life-years (QALYs) did not differ (1.10 vs 1.12; adjusted mean difference favouring infliximab treatment 0.01 (95% CI −0.07 to 0.08)). The incremental cost-effectiveness ratios for the infliximab versus conventional treatment strategy were €2 404 197/QALY from the societal perspective and €1 948 919/QALY from the healthcare perspective. Conclusions In early, methotrexate-refractory rheumatoid arthritis, a treatment strategy commencing with addition of infliximab, as compared to sulfasalazine+hydroxychloroquine, was not cost-effective over 21 months at willingness to pay levels generally considered acceptable. Trial registration number: NCT00764725.
Collapse
Affiliation(s)
- Jonas K Eriksson
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan A Karlsson
- Section of Rheumatology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Johan Bratt
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ingemar F Petersson
- Section of Rheumatology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden Section of Orthopedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | | | - Sofia Ernestam
- Department of Learning, Informatics and Medical Education (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Pierre Geborek
- Section of Rheumatology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Martin Neovius
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
28
|
Büsch K, Ludvigsson JF, Ekström-Smedby K, Ekbom A, Askling J, Neovius M. Nationwide prevalence of inflammatory bowel disease in Sweden: a population-based register study. Aliment Pharmacol Ther 2014; 39:57-68. [PMID: 24127738 DOI: 10.1111/apt.12528] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 07/03/2013] [Accepted: 09/21/2013] [Indexed: 01/14/2023]
Abstract
BACKGROUND Regional studies on inflammatory bowel disease (IBD) suggest an increasing prevalence over time, but no nationwide estimate has been published so far. AIM To estimate the IBD prevalence in 2010 in Sweden overall, by disease, and in specific patient segments. METHODS Patients were identified according to international classification codes for ulcerative colitis and Crohn's disease in in-patient care (1987-2010), day surgery and nonprimary out-patient care (1997-2010) in the nationwide Swedish Patient Register. RESULTS Requiring two or more diagnoses of IBD in nonprimary care, a total of 61 344 individuals with physician-diagnosed IBD were alive in Sweden in 2010 (mean age 50 years; 51% men), corresponding to a prevalence of 0.65% (95% CI, 0.65-0.66). The prevalence increased with age, and peaked in women at ages 50-59 years and in men at ages 60-69 years. Adding the requirement of IBD as main (vs. main or contributory) diagnosis code, or diagnosis from an internal medicine/gastroenterology/surgery department did not change the prevalence estimate. Prevalence of actively treated disease (defined as two or more IBD-related visits, of which one occurred in 2010, plus at least one dispensed prescription of IBD-related drugs in 2010) was 0.27% (95% CI, 0.27-0.28). CONCLUSIONS The Swedish nationwide register-based IBD prevalence was higher compared with previous Swedish and international estimates. While prevalence estimates were robust across different case definitions, once two or more visits were required, only about one-third of prevalent patients were drawing resources from specialised care in 2010.
Collapse
Affiliation(s)
- K Büsch
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | | | | |
Collapse
|
29
|
Neovius M, Arkema EV, Olsson H, Eriksson JK, Kristensen LE, Simard JF, Askling J. Drug survival on TNF inhibitors in patients with rheumatoid arthritis comparison of adalimumab, etanercept and infliximab. Ann Rheum Dis 2013; 74:354-60. [PMID: 24285495 PMCID: PMC4316855 DOI: 10.1136/annrheumdis-2013-204128] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective To compare drug survival on adalimumab, etanercept and infliximab in patients with rheumatoid arthritis (RA). Methods Patients with RA (n=9139; 76% women; mean age 56 years) starting their first tumour necrosis factor (TNF) inhibitor between 2003 and 2011 were identified in the Swedish Biologics Register (ARTIS). Data were collected through 31 December 2011. Drug survival over up to 5 years of follow-up was compared overall and by period of treatment start (2003–2005/2006–2009; n=3168/4184) with adjustment for age, sex, education, period, health assessment questionnaire (HAQ), disease duration, concomitant disease modifying antirheumatic drug (DMARD) treatment and general frailty (using hospitalisation history as proxy). Results During 20 198 person-years (mean/median 2.2/1.7 years) of follow-up, 3782 patients discontinued their first biological (19/100 person-years; 51% due to inefficacy, 36% due to adverse events). Compared with etanercept, infliximab (adjusted HR 1.63, 95% CI 1.51 to 1.77) and adalimumab initiators had higher discontinuation rates (1.26, 95% CI 1.16 to 1.37), and infliximab had a higher discontinuation rate than adalimumab (1.28, 95% CI 1.18 to 1.40). These findings were consistent across periods, but were modified by time for adalimumab versus etanercept (p<0.001; between-drug difference highest the 1st year in both periods). The discontinuation rate was higher for starters in 2006–2009 than 2003–2005 (adjusted HR 1.12, 95% CI 1.04 to 1.20). The composition of 1-year discontinuations also changed from 2003–2005 vs 2006–2009: adverse events decreased from 45% to 35%, while inefficacy increased from 43% to 53% (p<0.001). Conclusions Discontinuation rates were higher for infliximab compared with adalimumab and etanercept initiators, and for adalimumab versus etanercept during the 1st year. Discontinuation rates increased with calendar period, as did the percentage discontinuations due to inefficacy.
Collapse
Affiliation(s)
- M Neovius
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - E V Arkema
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - H Olsson
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - J K Eriksson
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - L E Kristensen
- Department of Rheumatology, Lund University, Lund, Sweden
| | - J F Simard
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - J Askling
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden Rheumatology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | | |
Collapse
|
30
|
Kalkan A, Hallert E, Bernfort L, Husberg M, Carlsson P. Costs of rheumatoid arthritis during the period 1990-2010: a register-based cost-of-illness study in Sweden. Rheumatology (Oxford) 2013; 53:153-60. [PMID: 24136064 DOI: 10.1093/rheumatology/ket290] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES The objectives of this study were to analyse the total socio-economic impact of RA in Sweden during the period 1990-2010 and to analyse possible changes in costs during this period. The period was deliberately chosen to cover 10 years before and 10 years after the introduction of biologic drugs. METHODS A prevalence-based cost-of-illness study was conducted based on data from national and regional registries. RESULTS There was a decrease in the utilization of RA-related inpatient care as well as sick leave and disability pension during 1990-2010 in Sweden. Total costs for RA are presented in current prices as well as inflation-adjusted with the consumer price index (CPI) and a healthcare price index. The total fixed cost of RA was €454 million in 1990, adjusted to the price level of 2010 with the CPI. This cost increased to €600 million in 2010 and the increase was mainly due to the substantially increasing costs for pharmaceuticals. Of the total costs, drug costs increased from 3% to 33% between 1990 and 2010. Consequently the portion of total costs accounting for indirect costs for RA is lowered from 75% in 1990 to 58% in 2010. CONCLUSION By inflation adjusting with the CPI, which is reasonable from a societal perspective, there was a 32% increase in the total fixed cost of RA between 1990 and 2010. This suggests that decreased hospitalization and indirect costs have not fallen enough to offset the increasing cost of drug treatment.
Collapse
Affiliation(s)
- Almina Kalkan
- Division of Health Care Analysis, Department of Medical and Health Sciences, Linköping University, SE-581 83 Linköping, Sweden.
| | | | | | | | | |
Collapse
|
31
|
Putrik P, Ramiro S, Kvien TK, Sokka T, Uhlig T, Boonen A. Variations in criteria regulating treatment with reimbursed biologic DMARDs across European countries. Are differences related to country's wealth? Ann Rheum Dis 2013; 73:2010-21. [PMID: 23940213 DOI: 10.1136/annrheumdis-2013-203819] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To explore criteria regulating treatment with reimbursed biologic disease-modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA) across Europe and to relate criteria to indicators of national socioeconomic welfare. METHODS A cross-sectional study among 46 European countries. One expert from each country completed a questionnaire on criteria regulating the start, maintenance/stop and switch of reimbursed bDMARDs. A composite score was developed to evaluate the level of restrictions in prescription of a first bDMARD (0=highly restricted, 5=most liberal). The level of restrictiveness was correlated with national socioeconomic welfare indicators. RESULTS In 10 countries (22%), no bDMARD was reimbursed. Among 36 countries with at least one biologic reimbursed, 23(64%) had no requirement for disease duration to initiate a biologic. Half of the countries required a failure of two synthetic DMARDs to qualify for therapy. 31 countries specified a minimum level of disease activity to be fulfilled and in 20 (56%) countries cut-off for disease activity score with 28-joint assessment was higher than 3.2. Four countries (11%) had the maximum composite score (most liberal) and 20 (56%) scored between 0 and 2 (more restrictive). Criteria for initiation of a bDMARD were negatively associated with countries' socioeconomic welfare (-0.34 to -0.64), and a moderate positive correlation was found between the composite score and welfare indicators (0.59-0.72). Only some countries had regulations for stopping (n=14(39%)) or switching (n=19(53%)). CONCLUSIONS Clinical criteria regulating prescription of bDMARDs in RA differ significantly across Europe. Countries with lower socioeconomic welfare tend to have stricter eligibility criteria, pointing to inequities in access to treatment.
Collapse
Affiliation(s)
- Polina Putrik
- Department of Health Promotion and Education, Maastricht University, School for Public Health and Primary Care (CAPHRI), Maastricht, The Netherlands
| | - Sofia Ramiro
- Department of Clinical Immunology & Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Department of Rheumatology, Hospital Garcia de Orta, Almada, Portugal
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Tuulikki Sokka
- Department of Medicine, Jyväskylä Central Hospital, Jyvaskyla, Finland
| | - Till Uhlig
- Department of Rheumatology, National Research Center for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Annelies Boonen
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center and School for Public Health & Primary Care (CAPHRI), University Maastricht, Maastricht, The Netherlands
| | | |
Collapse
|
32
|
Eriksson JK, Neovius M, Ernestam S, Lindblad S, Simard JF, Askling J. Incidence of Rheumatoid Arthritis in Sweden: A Nationwide Population-Based Assessment of Incidence, Its Determinants, and Treatment Penetration. Arthritis Care Res (Hoboken) 2013; 65:870-8. [DOI: 10.1002/acr.21900] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 10/25/2012] [Indexed: 11/08/2022]
|
33
|
Cars T, Wettermark B, Malmström RE, Ekeving G, Vikström B, Bergman U, Neovius M, Ringertz B, Gustafsson LL. Extraction of Electronic Health Record Data in a Hospital Setting: Comparison of Automatic and Semi‐Automatic Methods Using Anti‐
TNF
Therapy as Model. Basic Clin Pharmacol Toxicol 2013; 112:392-400. [DOI: 10.1111/bcpt.12055] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Accepted: 01/21/2013] [Indexed: 12/25/2022]
Affiliation(s)
- Thomas Cars
- Public Healthcare Services Committee Administration Stockholm County Council Stockholm Sweden
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Björn Wettermark
- Public Healthcare Services Committee Administration Stockholm County Council Stockholm Sweden
- Centre for Pharmacoepidemiology Department of Medicine Karolinska Institutet Stockholm Sweden
- Division of Clinical Pharmacology Department of Laboratory Medicine Karolinska Institutet at Karolinska University Hospital Stockholm Sweden
| | - Rickard E. Malmström
- Division of Clinical Pharmacology Department of Medicine Karolinska Institutet at Karolinska University Hospital Solna Stockholm Sweden
| | - Gunnar Ekeving
- Department of IT Management Karolinska University Hospital Stockholm Sweden
| | - Bo Vikström
- TakeCare Cooperation Centre Karolinska University Hospital Stockholm Sweden
| | - Ulf Bergman
- Centre for Pharmacoepidemiology Department of Medicine Karolinska Institutet Stockholm Sweden
- Division of Clinical Pharmacology Department of Laboratory Medicine Karolinska Institutet at Karolinska University Hospital Stockholm Sweden
| | - Martin Neovius
- Clinical Epidemiology Unit Department of Medicine Karolinska Institutet Stockholm Sweden
| | - Bo Ringertz
- Division of Rheumatology Department of Medicine Karolinska Institutet at Karolinska University Hospital Solna Stockholm Sweden
| | - Lars L. Gustafsson
- Division of Clinical Pharmacology Department of Laboratory Medicine Karolinska Institutet at Karolinska University Hospital Stockholm Sweden
| |
Collapse
|
34
|
Putrik P, Ramiro S, Kvien TK, Sokka T, Pavlova M, Uhlig T, Boonen A. Inequities in access to biologic and synthetic DMARDs across 46 European countries. Ann Rheum Dis 2013; 73:198-206. [PMID: 23467636 DOI: 10.1136/annrheumdis-2012-202603] [Citation(s) in RCA: 252] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES We investigated access to biologic and synthetic disease modifying drugs (bDMARDs and sDMARDs) in patients with rheumatoid arthritis (RA) across Europe. METHODS A cross-sectional study at national level was performed in 49 European countries. A questionnaire was sent to one expert, addressing the number of approved and reimbursed bDMARDs and sDMARDs, prices and co-payments, as well as acceptability of bDMARDs (barriers). Data on socio-economic welfare (gross domestic product per capita (GDP), health expenditure, income) were retrieved from web-based sources. Data on health status of RA patients were retrieved from an observational study. Dimensions of access (availability, affordability and acceptability) were correlated with the country's welfare and RA health status. RESULTS In total, 46 countries (94%) participated. Six countries did not reimburse any of the five sDMARDs surveyed, and in ten countries no bDMARDs were reimbursed. While the price of annual treatment with an average sDMARD was never higher than GPD, the price of one year treatment with a bDMARD exceeded GPD in 26 countries. Perceived barriers for access to bDMARDs were mainly found among financial and administrative restrictions. All dimensions of access were positively correlated with the country's economic welfare (coefficients 0.69 to 0.86 for overall access scores). CONCLUSIONS Patients with RA in lower income European countries have less access to bDMARDs and sDMARDs, with particularly striking unaffordability of bDMARDs in some of these countries. When accepting that sDMARDs and bDMARDs are equally needed across countries to treat RA, our data point to inequities in access to pharmacological treatment for RA in Europe.
Collapse
Affiliation(s)
- Polina Putrik
- Department of Health Promotion and Education, Maastricht University, School for Public Health and Primary Care (CAPHRI), , Maastricht, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Simard JF, Neovius M, Askling J. Mortality rates in patients with rheumatoid arthritis treated with tumor necrosis factor inhibitors: drug-specific comparisons in the Swedish Biologics Register. ACTA ACUST UNITED AC 2013; 64:3502-10. [PMID: 22886739 DOI: 10.1002/art.34582] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine whether the differences in the modes of action and safety profiles of individual tumor necrosis factor inhibitors (TNFi) translate into differential mortality risks, as investigated in etanercept, infliximab, and adalimumab. METHODS Data on patients with rheumatoid arthritis (RA) identified in the Swedish Biologics Register (Anti-Rheumatic Therapy in Sweden [ARTIS]) in whom first-ever treatment with a biologic agent (etanercept [n = 2,686], infliximab [n = 2,027], or adalimumab [n = 1,609]) was initiated between 2003 and 2008 were linked to national Swedish registers to get information on deaths from any cause, demographic features, RA characteristics, comorbid conditions, and concurrent treatment at the start of TNFi treatment. Hazard ratios (HRs) were modeled using multivariable adjusted and weighted Cox models. RESULTS During 19,118 person-years of followup, 211 patients died (3.3%; 1.1 deaths per 100 person-years); 85% of the deaths occurred among patients who had been exposed to only one TNFi. We found no statistically significant difference in overall mortality rates across the exposure groups, regardless of adjustment and modeling approach (for infliximab versus etanercept, HR 1.1 [95% confidence interval (95% CI) 0.7-1.7], and for adalimumab versus etanercept, HR 1.3 [95% CI 0.9-2.0]). CONCLUSION Overall, we noted no statistically significant difference in mortality rates between the 3 TNF inhibitors under study. Further studies need to examine whether certain subsets of patients are at increased risk of death with specific TNFi.
Collapse
|
36
|
Karlsson JA, Neovius M, Nilsson JÅ, Petersson IF, Bratt J, van Vollenhoven RF, Ernestam S, Geborek P. Addition of infliximab compared with addition of sulfasalazine and hydroxychloroquine to methotrexate in early rheumatoid arthritis: 2-year quality-of-life results of the randomised, controlled, SWEFOT trial. Ann Rheum Dis 2012. [PMID: 23196701 DOI: 10.1136/annrheumdis-2012-202062] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To compare EuroQol 5-Dimensions (EQ-5D) utility and quality-adjusted life-years (QALYs) in patients with early, methotrexate (MTX) refractory rheumatoid arthritis (RA), randomised to addition of infliximab (IFX) or sulfasalazine and hydroxychloroquine (SSZ+HCQ). METHODS RA-patients with symptoms <1 year were enrolled between 2002 and 2005 at 15 Swedish centres. After 3-4 months of MTX monotherapy, patients with a remaining DAS28>3.2 were randomised to addition of IFX or SSZ+HCQ and followed for 21 months. EQ-5D profiles were collected every 3 months. Between-group comparisons of utility change and accumulated QALYs were performed, using last observation carried forward (LOCF) following protocol breach. Missing data were imputed by linear interpolation or LOCF. Sensitivity analyses applying baseline observation carried forward (BOCF) or restricted to completers were conducted. RESULTS Of 487 patients initially enrolled, 128 and 130 were randomised to IFX or SSZ+HCQ, respectively. Mean utility in the IFX and SSZ+HCQ groups increased from 0.52 (SD 0.27) and 0.55 (SD 0.27) at randomisation to 0.66 (SD 0.25) and 0.63 (SD 0.27) at 21 months (adjusted mean difference favouring IFX 0.04; 95% CI -0.01, 0.09; p=0.15). Average accumulated QALYs were 1.10 (SD 0.37) and 1.07 (SD 0.42) in the IFX and SSZ+HCQ groups, respectively (adjusted mean difference favouring IFX 0.07; 95%CI -0.01, 0.14; p=0.07). BOCF analysis showed similar results, while differences were reversed, though remained statistically non-significant among completers. Dropout rates in the IFX/SSZ+HCQ groups were 30%/43% (p=0.01). CONCLUSIONS Comparing addition of IFX or SSZ+HCQ to MTX in active early RA, no statistically significant differences in utility or QALY gain could be detected over 21 months. TRIAL REGISTRATION Registered in WHO database at the Karolinska University Hospital, number CT20080004.
Collapse
Affiliation(s)
- Johan A Karlsson
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, , Lund, Sweden
| | | | | | | | | | | | | | | |
Collapse
|
37
|
Impact of socioeconomic gradients within and between countries on health of patients with rheumatoid arthritis (RA): Lessons from QUEST RA. Best Pract Res Clin Rheumatol 2012; 26:705-20. [DOI: 10.1016/j.berh.2012.07.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2012] [Indexed: 12/29/2022]
|
38
|
Grönhagen CM, Fored CM, Linder M, Granath F, Nyberg F. Subacute cutaneous lupus erythematosus and its association with drugs: a population-based matched case-control study of 234 patients in Sweden. Br J Dermatol 2012; 167:296-305. [PMID: 22458771 DOI: 10.1111/j.1365-2133.2012.10969.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Numerous case reports about drug-induced (DI) subacute cutaneous lupus erythematosus (SCLE) have been published. Various drug types with different latencies has been proposed as triggers for this autoimmune skin disease. OBJECTIVES To evaluate the association between exposure to certain suspected drugs (previously implicated to induce SCLE) and a subsequent diagnosis of SCLE. METHODS We performed a population-based matched case-control study in which all incident cases of SCLE (n=34) from 2006 to 2009 were derived from the National Patient Register. The control group was selected from the general population, matched (1:10) for gender, age and county of residence. The data were linked to the Prescribed Drug Register. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for the association between exposures to certain suspected drugs and the development of SCLE. RESULTS During the 6 months preceding SCLE diagnosis, 166 (71%) of the patients with SCLE had at least one filled prescription of the suspected drugs. The most increased ORs were found for terbinafine (OR 52.9, 95% CI 6.6-∞), tumour necrosis factor-α inhibitors (OR 8.0, 95% CI 1.6-37.2), antiepileptics (OR 3.4, 95% CI 1.9-5.8) and proton pump inhibitors (OR 2.9, 95% CI 2.0-4.0). CONCLUSIONS We found an association between drug exposure and SCLE. More than one third of the SCLE cases could be attributed to drug exposure. No significant OR was found for thiazides, which might be due to longer latency and therefore missed with this study design. DI-SCLE is reversible once the drug is discontinued, indicating the importance of screening patients with SCLE for potentially triggering drugs. A causal relationship cannot be established from this study and the underlying pathogenesis remains unclear.
Collapse
Affiliation(s)
- C M Grönhagen
- Division of Dermatology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, SE-182 88 Danderyd, Sweden.
| | | | | | | | | |
Collapse
|
39
|
Windt R, Glaeske G, Hoffmann F. [Prescription of TNF-alpha inhibitors and regional differences in 2010]. Z Rheumatol 2012; 70:874-81. [PMID: 21956828 DOI: 10.1007/s00393-011-0873-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tumor necrosis factor alpha (TNF-α) inhibitors are an important treatment option for rheumatoid arthritis and other chronic inflammatory diseases. However, attention should be paid to severe adverse drug reactions and very high costs of therapy. The objective of this study was to examine the prescription and costs of TNF-α inhibitors as well as regional differences at the district level in Germany. For this purpose, prescription claims data of a German health fund with 9.1 million insured persons from the year 2010 were analyzed. A total of 45,229 packs (0.1% of all prescribed drugs) and 3.15 million defined daily doses (DDD) of TNF-α inhibitors were prescribed. This leads to a total pharmacy revenue of 163.18 million Euro (share 4.1%) and 1 DDD costs on average 51.61 Euro. For 10,078 patients at least one TNF inhibitor was prescribed (prescription prevalence 111 per 100,000) with a higher proportion of women (125 vs. 92 per 100,000). The average revenue per insured person was often higher in districts of eastern Germany (>30 Euro) for reasons unknown. Provided that use is appropriate to indications there are only low saving potentials.
Collapse
Affiliation(s)
- R Windt
- Zentrum für Sozialpolitik, Abteilung Gesundheitsökonomie, Gesundheitspolitik und Versorgungsforschung, Universität Bremen, Mary-Somerville-Str. 5, 28359, Bremen, Deutschland.
| | | | | |
Collapse
|
40
|
Personal and family history of immune-related conditions increase the risk of plasma cell disorders: a population-based study. Blood 2011; 118:6284-91. [PMID: 21998210 DOI: 10.1182/blood-2011-04-347559] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The associations between immune-related conditions and multiple myeloma (MM) and monoclonal gammopathy of undetermined significance (MGUS) have previously been investigated with inconsistent results. In a large population-based study, we identified 19 112 patients with MM, 5403 patients with MGUS, 96 617 matched control subjects, and 262 931 first-degree relatives. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for the association of MM and MGUS with immune-related conditions by use of logistic regression. A personal history of all infections combined was associated with a significantly increased risk of MM (OR = 1.2; 95% CI, 1.1-1.3), and a personal history of all conditions in the categories infections (OR = 1.6; 95% CI, 1.5-1.7), inflammatory conditions (OR = 1.4; 95% CI, 1.2-1.5), and autoimmune diseases (OR = 2.1; 95% CI, 1.9-2.4) was associated with a significantly increased risk of MGUS. Several specific immune-related conditions elevated the risk of MM and/or MGUS. A family history of autoimmune disease was associated with a significantly increased risk of MGUS (OR = 1.1; 95% CI, 1.00-1.2), but not MM. Our findings suggest that immune-related conditions and/or their treatment are of importance in the etiology of MGUS and possibly MM. The association of both personal and family history of autoimmune disease with MGUS indicates the potential for shared susceptibility for these conditions.
Collapse
|
41
|
Ohlsson H, Merlo J. Small-area variations in sales of TNF inhibitors in Sweden between 2000 and 2009: comments on the article by M Neovius et al. Scand J Rheumatol Suppl 2011; 40:243-4. [DOI: 10.3109/03009742.2011.574644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|