Superior Effectiveness of Tofacitinib Compared to Vedolizumab in Anti-TNF-experienced Ulcerative Colitis Patients: A Nationwide Dutch Registry Study

BACKGROUND & AIMS

Clinicians face difficulty in when and in what order to position biologics and Janus kinase inhibitors in patients with anti-tumor necrosis factor-alpha (TNF) refractory ulcerative colitis (UC). We aimed to compare the effectiveness and safety of vedolizumab and tofacitinib in anti-TNF-exposed patients with UC in our prospective nationwide Initiative on Crohn and Colitis Registry.

METHODS

Patients with UC who failed anti-TNF treatment and initiated vedolizumab or tofacitinib treatment were identified in the Initiative on Crohn and Colitis Registry in the Netherlands. We selected patients with both clinical as well as biochemical or endoscopic disease activity at initiation of therapy. Patients previously treated with vedolizumab or tofacitinib were excluded. Corticosteroid-free clinical remission (Simple Clinical Colitis Activity Index ≤2), biochemical remission (C-reactive protein ≤5 mg/L or fecal calprotectin ≤250 μg/g), and safety outcomes were compared after 52 weeks of treatment. Inverse propensity score-weighted comparison was used to adjust for confounding and selection bias.

RESULTS

Overall, 83 vedolizumab- and 65 tofacitinib-treated patients were included. Propensity score-weighted analysis showed that tofacitinib-treated patients were more likely to achieve corticosteroid-free clinical remission and biochemical remission at weeks 12, 24, and 52 compared with vedolizumab-treated patients (odds ratio [OR], 6.33; 95% confidence interval [CI], 3.81-10.50; P < .01; OR, 3.02; 95% CI, 1.89-4.84; P < .01; and OR, 1.86; 95% CI, 1.15-2.99; P = .01; and OR, 3.27; 95% CI, 1.96-5.45; P < .01; OR, 1.87; 95% CI, 1.14-3.07; P = .01; and OR, 1.81; 95% CI, 1.06-3.09; P = .03, respectively). There was no difference in infection rate or severe adverse events.

CONCLUSIONS

Tofacitinib was associated with superior effectiveness outcomes compared with vedolizumab in anti-TNF-experienced patients with UC along with comparable safety outcomes.

Novel ways to fund cost-efficiency studies of expensive drugs: Efforts to maintain sustainable healthcare expenditure in the Netherlands

e18831

Background: The rising costs of new cancer drugs is a major burden for healthcare system. Healthcare providers and payers constantly look for solutions to reduce inefficient use of these drugs. Methods: These solutions may involve dose-rounding, dose-banding or vial-sharing to minimise the quantity of discarded pharmaceuticals. Alternative dosing strategies, such as tapering and/or increasing the dose-interval, shortening treatment duration, or boosting potency of the drugs may also be applied. Another approach is the development of predictive/monitoring biomarkers that can prevent mis-prescribing and overuse of therapies to patients who will not benefit from such a therapy. Provided that the therapeutic benefit is retained, a lower drug exposure evidently not only results in savings for the national healthcare budget but may also limit (off-target) toxicity, reduce hospitalisation and improve quality-of-life for patients. Results: Once compelling evidence of non-inferiority is available, the roll-out one of the strategies mentioned above is justified. Parties providing financial support for cost-efficiency initiatives are then often eager to support implementation and generate potential shared savings. However, when (additional) research is required to generate adequate evidence, fund raising and finding support can be quite challenging. In the Netherlands a dedicated national fund was recently established. Treatmeds, a foundation under Dutch law, is tasked to support cost-efficiency studies and to secure and manage (part of) the funding needed for those initiatives. Treatmeds is backed by Dutch healthcare insurers. Its governance provides for decisions based on the advice of an independent Scientific Advisory Board, an Intervention Board and a Financial Board. The Scientific Advisory Board aides with selecting studies for support on a pure scientific basis, the Intervention Board considers aspects as efficiency, the possibility of reimbursement under the Dutch compulsory healthcare insurance, the cost-benefit ratio of a study and the Financial Board ultimately decides on the financial aspects of supporting a study. Although Treatmeds only has just started its activities, it is expected that it can have a pivotal role in acceleration of efficiency tools in clinical practice. Conclusions: From our own experience we can state that a dedicated national fund supporting research on improved efficiency and quality of care can be of great value to accelerate study start-up and roll-out.