POS0448 DISCONTINUATION RATE OF TOFACITINIB AS MONOTHERAPY IS SIMILAR COMPARED TO COMBINATION THERAPY WITH METHOTREXATE IN RHEUMATOID ARTHRITIS PATIENTS: POOLED DATA FROM TWO RHEUMATOID ARTHRITIS REGISTRIES IN CANADA

Background:

Tofacitinib (TOFA) is an oral, small molecule drug used for rheumatoid arthritis (RA) treatment and is prescribed alone or with methotrexate (MTX). We previously reported the similarity in retention between TOFA monotherapy and TOFA with MTX using data from two different registries separately; the Ontario Best Practices Research Initiative (OBRI) and the Quebec registry RHUMADATA.

Objectives:

To increase the study power, we propose to evaluate the discontinuation rate (due to any reason) of TOFA with and without MTX, using pooled data from these two registries.

Methods:

RA patients enrolled in the OBRI and RHUMADATA initiating their TOFA between 1st June 2014 (TOFA approval date in Canada) and 31st Dec 2019 were included. Concurrent MTX use was defined as MTX use for more than 75% of the time while using TOFA. Multiple imputation (Imputation Chained Equation method, N=20) was used to deal with missing data for covariates at treatment initiation.

Time to discontinuation was assessed using Cox regression models. To deal with confounding by indication, we estimated propensity scores for selected covariates with an absolute standard difference greater than 0.1. We then adjusted Cox regression models for propensity quantile to compare the discontinuation of TOFA with MTX versus TOFA without MTX.

Results:

A total of 493 patients were included. Of those, 244 (49.5%) and 249 (51.5%) were treated with MTX and without MTX, respectively. Compared to TOFA monotherapy, the TOFA with MTX group had a significantly lower mean HAQ-DI, fatigue score, and the number of prior biologic use at the time of TOFA initiation. A lower proportion of positive ACPA (59% vs. 66%), prevalence of hypertension (31% vs 37%), and concomitant use of Leflunomide (11% vs. 23%) were also observed for patients using TOFA with MTX.

Over a mean follow-up of 19.0 months, discontinuation was reported in 182 (36.9%) of all TOFA patients. After adjusting for propensity score quantile across 20 imputed datasets, there was no significant difference in discontinuation between treatment groups (adjusted HRs: 1.12, 95% CI: 0.83-1.51; p=0.49).

Conclusion:

In this pooled real-world data study, we found that in patients with RA, the retention of TOFA is similar if it is used as monotherapy or in combination with MTX.

Disclosure of Interests:

Movahedi: None declared, Denis Choquette Grant/research support from: Rhumadata is supported by unrestricted grants from Abbvie Canada, Amgen Canada, Eli Lilly Canada, Novartis Canada, Pfizer Canada, Sandoz Canada and Sanofi Canada., Louis Coupal: None declared, Angela Cesta: None declared, Xiuying Li: None declared, Edward Keystone Grant/research support from: Amgen, Merck, Pfizer Pharmaceuticals, PuraPharm. Speaker Honoraria Agreements: AbbVie, Amgen, Bristol-Myers Squibb Company, Celltrion, Myriad Autoimmune, F. Hoffmann-La Roche Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, Sanofi-Genzyme, Samsung Bioepsis. Consulting Agreements/Advisory Board Membership: AbbVie, Amgen, Bristol-Myers Squibb Company, Celltrion, Myriad Autoimmune, F. Hoffmann-La Roche Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, Sanofi-Genzyme, Samsung Bioepsis, Claire Bombardier Grant/research support from: OBRI was funded by peer reviewed grants from CIHR (Canadian Institute for Health Research), Ontario Ministry of Health and Long-Term Care (MOHLTC), Canadian Arthritis Network (CAN) and unrestricted grants from: Abbvie, Amgen, Aurora, Bristol-Meyers Squibb, Celgene, Hospira, Janssen, Lilly, Medexus, Merck, Novartis, Pfizer, Roche, Sanofi, & UCB.

Acknowledgment: :

Dr. Bombardier held a Canada Research Chair in Knowledge Transfer for Musculoskeletal Care and a Pfizer Research Chair in Rheumatology

OP0179 DISCONTINUATION RATE OF TOFACITINIB IS SIMILAR WHEN COMPARED TO TNF INHIBITORS IN RHEUMATOID ARTHRITIS PATIENTS: POOLED DATA FROM TWO RHEUMATOID ARTHRITIS REGISTRIES IN CANADA

Background:

Tofacitinib (TOFA) is an oral, small molecule drug used for rheumatoid arthritis (RA) treatment as the first or an alternative option to biologic disease- modifying antirheumatic drugs (bDMARDs), including tumor necrosis factor inhibitors (TNFi). The similarity in retention of TNFi and TOFA was previously reported separately by the Ontario Best Practices Research Initiative (OBRI) and the Quebec cohort RHUMADATA®.

Objectives:

To increase the study power, we propose to evaluate the discontinuation rate (due to any reason) of TNFi compared to TOFA, using pooled data from both these registries.

Methods:

RA patients enrolled in the OBRI and RHUMADATA initiating their TOFA or TNFi between 1st June 2014 (TOFA approval date in Canada) and 31st Dec 2019 were included. Time to discontinuation was assessed using adjusted Kaplan-Meier (KM) survival and Cox regression models. To deal with confounding by indication, we estimated propensity scores for covariates with a standard difference greater than 0.1. Models were then adjusted using stratification and inverse probability of treatment weight (IPTW) methods. Multiple imputation (Imputation by Chained Equation method, N=20) was used to deal with missing data for covariates at treatment initiation.

Results:

A total of 1318 patients initiated TNFi (n=825) or TOFA (n=493) with mean (SD) disease duration of 8.9 (9.3) and 13.0 (10.1) years, respectively. In the TNFi group, 78.8% were female and mean age (SD) at treatment initiation was 57.6 (12.6) years. In the TOFA group, 84.6% were female and mean (SD) age at treatment initiation was 59.5 (11.5) years. The TNFi group was less likely to have prior biologic use (33.9%) than the TOFA group (66.9%). At treatment initiation, the mean (SD) CDAI was significantly (p<0.05) lower in the TNFi group [20.0 (11.7)] compared to the TOFA group [22.1(12.4)]. Physical function measured by HAQ-DI was also significantly lower (p<0.05) in the TNFi compared to the TOFA group (1.2 vs.1.3).

Over a mean follow-up of 23.2 months, discontinuation was reported in 309 (37.5%) and 182 (36.9%) of all TNFi and TOFA patients, respectively. After adjusting for propensity score deciles across 20 imputed datasets, there was no significant difference in discontinuation between treatment groups (adjusted HRs: 0.96, 95% CI: 0.78-1.18; p=0.69). The results were similar for two propensity adjustment methods. Figure 1 shows IPTW adjusted KM survival curves comparing discontinuation rates in patients treated with TNFi and TOFA.

Figure 1.

Note: Propensity Score Weighted (IPTW) Survival Curves was performed using one imputed dataset

Conclusion:

In this pooled real -world data study, we found that TNFi and TOFA retention is similar in patients with RA. In the next step we will analysis the data for specific reasons of dicontinutaion. We will also repeat analysis comparing discontinuation in the first users versus those after one or more biologic failure.

Disclosure of Interests:

Mohammad Movahedi: None declared, Denis Choquette Grant/research support from: Rhumadata® is supported by unrestricted grants from Abbvie Canada, Amgen Canada, Eli Lilly Canada, Novartis Canada, Pfizer Canada, Sandoz Canada and Sanofi Canada., Louis Coupal: None declared, Angela Cesta: None declared, Xiuying Li: None declared, Edward Keystone Grant/research support from: Amgen, Merck, Pfizer Pharmaceuticals, PuraPharm. Speaker Honoraria Agreements: AbbVie, Amgen, Bristol-Myers Squibb Company, Celltrion, Myriad Autoimmune, F. Hoffmann-La Roche Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, Sanofi-Genzyme, Samsung Bioepsis. Consulting Agreements/Advisory Board Membership: AbbVie, Amgen, Bristol-Myers Squibb Company, Celltrion, Myriad Autoimmune, F. Hoffmann-La Roche Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, Sanofi-Genzyme, Samsung Bioepsis, Claire Bombardier Grant/research support from: OBRI was funded by peer reviewed grants from CIHR (Canadian Institute for Health Research), Ontario Ministry of Health and Long-Term Care (MOHLTC), Canadian Arthritis Network (CAN) and unrestricted grants from: Abbvie, Amgen, Aurora, Bristol-Meyers Squibb, Celgene, Hospira, Janssen, Lilly, Medexus, Merck, Novartis, Pfizer, Roche, Sanofi, & UCB.

Dr. Bombardier held a Canada Research Chair in Knowledge Transfer for Musculoskeletal Care and a Pfizer Research Chair in Rheumatology

FRI0331 COMPARISON OF THE THERAPEUTIC TRAJECTORIES OF PATIENTS WITH OLIGO AND POLYARTICULAR PSORIATIC ARTHRITIS. A REPORT FROM THE RHUMADATA® CLINICAL DATABASE AND REGISTRY

Background:

Psoriatic Arthritis (PsA) most frequently presents as a polyarthritis or (less often) as an oligoarthritis [1]. Most of the patients in the original description of Moll and Wight had an oligoarticular presentation [2]. However, other studies have not found the same distribution in all patient populations [3]. Treatment response over time across presentation types has not been explored thoroughly in recent medical literature.

Objectives:

Using our proposed definition of oligo and polyarticular PsA status, based on the (rounded) mean of the first four available joint counts, we examine treatment sequences in each group.

Methods:

Data from patients participating in the RHUMADATA® clinical database and registry diagnosed with PsA were extracted on January 5th, 2020. Joint count classification (oligo vs. poly) was assessed from the average of the first four available 66/68 joint counts. Patients were classified as having a polyarticular form of PsA if the (rounded) average, five or more of their joints were assessed as being swollen and/or tender. Subjects with four or less swollen or tender joints were classified as patients having oligoarticular PsA. Time spent treated with non-DMARDs, csDMARDs and bDMARDs, time to treatment (to csDMARDs and bDMARDs) and treatment selection were assessed from the entire PsA cohort. Continuous variables were tested using t-tests and binary variables using Fisher’s exact test.

Results:

The data from all patients diagnosed with PsA (n=1029) was extracted from the RHUMADATA® clinical database and registry. All but 151 (15%) were classifiable, 470 (46%) were classified as oligoarticular PsA patients and 408 (39%) as polyarticular. Time from the first symptoms to the first clinic visit was 4.6 ± 6.5 years and 3.7 ± 6.6 (p-value=0.1311) years for the patients classified as oligo and poly respectively. A total oh 951 patients were treated with a csDMARD (144 of those could not be classified as oligo or poly). For those, time from diagnosis to first csDMARD (prior to any bDMARD) treatment was 1.7 ± 5.3 (oligo) years and 2.0 ± 7.0 (poly) years (p-value=0.4114). Methotrexate (MTX), hydroxychloroquine (HCQ) and leflunomide (LEF) were more frequently prescribed to polyarticular than oligoarticular PsA patients (MTX: 70% (poly) vs. 48% (oligo), p-value<.0001, HCQ: 41% vs. 25%, p-value <.0001, LEF: 17% vs. 8%, p-value<.0001, Sulfasalazine (SSZ): 17% vs. 19%, p-value=0.5232, Other csDMARDs: 5% vs. 4.5%, p-value=0.8688). A total of 648 patients were treated with a bDMARD (151 of those could not be classified as oligo or poly). For those, time from first csDMARD Rx to first bDMARD treatment was 6.3 ± 4.6 (oligo) years and 7.0 ± 4.7 years (p-value=0.0865). On average, over the entire treatment history, oligoarticular patients received 1.7 ± 1.2 biologic agents and polyarticular 2.0 ± 1.4, p-value=0.0110. bDMARDs were administered over 3.6 ± 3.6 years for oligo and 4.5 ± 3.9 years for poly, p-value=0.2122.

Conclusion:

Polyarticular PsA patients appear to be more aggressively treated than oligoarticular patients during the csDMARDs period. Although durations on bDMARDs are statistically similar, polyarticular patients change biotreatment more frequently.

References:

[1]Gladman DD, Ritchlin C, et al. Clinical manifestations and diagnosis of psoriatic arthritis. Update 2019.

[3]Wright V, Moll JM. Psoriatic arthritis. Bull Rheum Dis 1971; 21:627.

[3]Gladman DD. Psoriatic arthritis. Baillieres Clin Rheumatol 1995; 9:319.

Disclosure of Interests:

Denis Choquette Grant/research support from: Rhumadata is supported by grants from Pfizer, Amgen, Abbvie, Gylead, BMS, Novartis, Sandoz, eli Lilly,, Consultant of: Pfizer, Amgen, Abbvie, Gylead, BMS, Novartis, Sandoz, eli Lilly,, Speakers bureau: Pfizer, Amgen, Abbvie, Gylead, BMS, Novartis, Sandoz, eli Lilly,, Loïc Choquette Sauvageau: None declared, Louis Bessette Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Sanofi, Isabelle Ferdinand Consultant of: Pfizer, Abbvie, Amgen, Novartis, Speakers bureau: Pfizer, Amgen, Paul Haraoui Grant/research support from: AbbVie, Amgen, BMS, Janssen, Pfizer, Roche, and UCB, Consultant of: AbbVie, Amgen, BMS, Celgene, Eli Lilly, Janssen, Merck, Pfizer, Roche, and UCB, Speakers bureau: Pfizer, Speakers bureau: Amgen, BMS, Janssen, Pfizer, and UCB, Frédéric Massicotte Consultant of: Abbvie, Janssen, Lilly, Pfizer, Speakers bureau: Janssen, Jean-Pierre Pelletier Shareholder of: ArthroLab Inc., Grant/research support from: TRB Chemedica, Speakers bureau: TRB Chemedica and Mylan, Jean-Pierre Raynauld Consultant of: ArthroLab Inc., Marie-Anaïs Rémillard Consultant of: Abbvie, Amgen, Eli Lilly, Novartis, Pfizer, Sandoz, Paid instructor for: Abbvie, Amgen, Eli Lilly, Novartis, Pfizer, Sandoz, Speakers bureau: Abbvie, Amgen, Eli Lilly, Novartis, Pfizer, Sandoz, Diane Sauvageau: None declared, Édith Villeneuve Consultant of: Abbvie, Amgen, BMS, Celgene, Pfizer, Roche, Sanofi-Genzyme,

UCB, Paid instructor for: Abbvie, Speakers bureau: AbbVie, BMS, Pfizer, Roche, Louis Coupal: None declared

AB0752 PSORIATIC ARTHRITIS: OLIGOARTHRITIS AND POLYARTHRITIS PATTERN CHANGES OVER THE INITIAL YEAR OF THE PRESENTATION. A REAL-WORLD EVIDENCE REPORT FROM THE QUEBEC REGISTRY RHUMADATA®

Background:

Psoriatic Arthritis (PsA) most frequently presents as a polyarthritis or (less often) as an oligoarthritis [1]. Upon reassessment, patients may change category during follow-up [2-3]. Historically, the patients in the original description of Moll and Wight had an oligoarticular presentation [4]. However, other studies have not found the same distribution in all patient populations [5]. Currently, none of the accepted diagnostic or classification criteria set for PsA consider the variation in the number of involved joints in the early phase of PsA.

Objectives:

To evaluate the change in pattern between oligoarticular and polyarticular psoriatic arthritis, within the first year of follow-up.

Methods:

Data from RHUMADATA® patients diagnosed with PsA were extracted on December 8th, 2019. In the current analysis, we consider the first year of care patients following their first encounter with clinic staff. Patients with at least two 66/68 joint counts completed during this initial year are the subjects of this analysis. Joint count classification (Oligo vs Poly) was assessed from the first and last available joint counts. Patients were classified as having a polyarticular form of PsA if 5 or more of their joints were assessed as being swollen and/or tender. Subjects with 4 or less swollen and/or tender joints were classified as oligoarticular PsA patients.

Results:

A total of 287 patients with at least two 66/68 joint counts are used in the present analysis. At baseline, the mean age of patients was 47.8 ± 13.5 with average disease duration of 1.6 ± 5.2 years. 49 % of patients were women. Average joint count at baseline was 7.1 ± 7.2 (swollen) and 7.1 ± 7.5 (tender) joints. Considering only 28 joints, the average was 4.2 ± 5 and 3.9 ± 4.8 for swollen and tender joints respectively. At the first joint count, 115 (40%) patients were assessed as “Oligo” and 172 (60%) as “Poly”, while 159 (55%) and 128 (45%) were similarly assessed at the last assessment. The two assessments agreed for 179 (62%) and disagreed for 108 (38%). Of the 115 patients initially classified as “Oligo”, 32 (28%) were reassessed as “Poly” within the initial year, while 76 (44%) of the 172 patients initially classified as “Poly” were reassessed as “Oligo”. All 172 patients initially classified as “Poly” initiated a DMARD during this period (167 (97%) initiated a csDMARD and 5 (3%) initiated a bDMARS). All patients initially classified as “Oligo” also initiated treatment during this period (98 (85%) and 17 (15%) of the 115 patients initially classified as “Oligo” initiated csDMARDs and bDMARD respectively).

Conclusion:

These observations suggest that a single assessment of joint count may be misleading in establishing the oligo or polyarticular pattern of PsA. This classification should take treatment into account.

References:

[1]Gladman DD, Ritchlin C, et al. Clinical manifestations and diagnosis of psoriatic arthritis. Uptodate 2019.

[2]Jones SM, Armas JB, Cohen MG, et al. Psoriatic arthritis: outcome of disease subsets and relationship of joint disease to nail and skin disease. Br J Rheumatol 1994; 33:834.

[3]McHugh NJ, Balachrishnan C, Jones SM. Progression of peripheral joint disease in psoriatic arthritis: a 5-yr prospective study. Rheumatology (Oxford) 2003; 42:778.

[4]Wright V, Moll JM. Psoriatic arthritis. Bull Rheum Dis 1971; 21:627.

[5]Gladman DD. Psoriatic arthritis. Baillieres Clin Rheumatol 1995; 9:319.

Disclosure of Interests:

Sana Chambah: None declared, Louis Coupal: None declared, Denis Choquette Grant/research support from: Rhumadata is supported by grants from Pfizer, Amgen, Abbvie, Gylead, BMS, Novartis, Sandoz, eli Lilly,, Consultant of: Pfizer, Amgen, Abbvie, Gylead, BMS, Novartis, Sandoz, eli Lilly,, Speakers bureau: Pfizer, Amgen, Abbvie, Gylead, BMS, Novartis, Sandoz, eli Lilly,

THU0179 PERSISTENCE IN RHEUMATOID ARTHRITIS PATIENTS ON BIOSIMILAR AND BIO-ORIGINATOR ETANERCEPT: A POOLED ANALYSIS OF PAN-CANADIAN COHORTS

Background:

Biosimilar etanercept (ETA-B) was recently introduced in Canada but real-world data descriptions of drug persistence (and comparisons with the originator product, ETA-O) are still scarce.

Objectives:

To describe and compare persistence of ETA-B and ETA-O in RA.

Methods:

We used data from four ongoing, prospective cohorts in Canada: the Canadian Early Arthritis Cohort (CATCH), the Rheumatoid Arthritis Pharmacovigilance Program and Outcomes Research in Therapeutics (RAPPORT), the Early Undifferentiated Polyarthritis (EUPA) cohort, and the RHUMADATA® registry. We studied biologic-naïve and biologic-experienced RA adults initiating ETA-B or ETA-O between Jan. 2015 and Oct. 2019. Switchers from ETA-O to ETA-B (or vice-versa) were included. We assessed persistence of therapy in the first 12 or 24 months, measured as time from therapy initiation (time zero) to discontinuation. Individuals switching between products could contribute further person-time to the new exposure category. Multivariable Cox regression models were performed with each cohort dataset separately, following a common protocol. Model variables included age, sex, comorbidity, past biologic use, and disease duration. After testing for between-study heterogeneity (Higgin’s I2), cohort-estimated hazard ratios (HR) were pooled using random effects meta-analysis.

Results:

We identified 262 episodes of etanercept use (118 ETA-B and 144 ETA-O) from 250 RA patients. Sex, age, and other baseline characteristics across the four cohorts are shown in Table 1. Across cohorts, there was considerable variation in RA duration at the time of initiating ETA-B or ETA-O. In the pooled analysis, the HR for discontinuation at 24 months comparing ETA-B to ETA-O was 0.51 (95% confidence interval, CI: 0.26-0.98). The pooled analysis for therapy discontinuation at 12 months adjusted HR in this analysis was 0.82 (95% CI: 0.42-1.60).

Table 1.

Characteristics of studied patients according to their treatment episodes, biosimilar etanercept (ETA-B) or bio-originator etanercept (ETA-O).

CharacteristicEUPARAPPORTRHUMADATACATCHETA-BETA-OETA-BETA-OETA-BETA-OETA-BETA-ON=19N=27N=32N=30N=39N=52N=28N=35Female sex, (%)12 (63)18 (67)20 (63)22 (73)28 (72)38 (73)20 (71)27 (77)Mean age in years1, SD59 (13)59 (16)51 (15)54 (15)59 (15)54 (15)55 (12)51 (13)Current smoker, (%)3 (17)5 (21)9 (32)5 (19)8 (21)9 (17)5 (18)8 (23)Cardiovascular disease, (%)0 (0)0 (0)1 (3.1)1 (3.3)8 (21)2 (4)NANADiabetes, (%)0 (0)0 (0)4 (13)1 (3)2 (5)3 (6)NANAHypertension, (%)NANA5 (16)4 (13)14 (36)22 (42)NANARA duration in years1, SD2 (3)7 (13)8 (6)12 (15)12 (12)9 (9)4 (4)3 (3)DAS-2812 (NA)4 (2.8)6 (1)6 (1)4 (2)4 (1)4.0 (2)4 (2)SDAI113 (14)44 (5)NANA21 (15)23 (8)23 (14)25 (16)Past oral steroids, N(%)Past biologic, N(%)15 (79)17 (63)6 (19)4 (13)29 (74)31 (60)9 (32)13 (37)Past non-biologic DMARD,8 (42)6 (22)2 (6)0 (0)21 (54)20 (38)19 (68)21 (60)N(%)19 (100)27 (100)30 (94)26 (87)39 (100)52(100)25 (89)33 (94)

1At time zero or at the closest date before time zero. SD=standard deviation

Conclusion:

Despite wide confidence intervals, the 24-month data suggested potential better persistence with ETA-B versus ETA-O, with a similar trend at 12 months. Some of the observed associations may be related to residual confounding (e.g. disease activity, time-dependent effects of concomitant medications) and/or survivorship bias (in patients transitioning from ETA-O to ETA-B).

Disclosure of Interests:

Cristiano S Moura: None declared, Denis Choquette Grant/research support from: Rhumadata is supported by grants from Pfizer, Amgen, Abbvie, Gylead, BMS, Novartis, Sandoz, eli Lilly,, Consultant of: Pfizer, Amgen, Abbvie, Gylead, BMS, Novartis, Sandoz, eli Lilly,, Speakers bureau: Pfizer, Amgen, Abbvie, Gylead, BMS, Novartis, Sandoz, eli Lilly,, Louis Coupal: None declared, Orit Schieir: None declared, Marie-France Valois: None declared, Vivian Bykerk: None declared, Gilles Boire Grant/research support from: Merck Canada (Registry of biologices, Improvement of comorbidity surveillance)

Amgen Canada (CATCH, clinical nurse)

Abbvie (CATCH, clinical nurse)

Pfizer (CATCH, Registry of biologics, Clinical nurse)

Hoffman-LaRoche (CATCH)

UCB Canada (CATCH, Clinical nurse)

BMS (CATCH, Clinical nurse, Observational Study Protocol IM101664. SEROPOSITIVITY IN A LARGE CANADIAN OBSERVATIONAL COHORT)

Janssen (CATCH)

Celgene (Clinical nurse)

Eli Lilly (Registry of biologics, Clinical nurse), Consultant of: Eli Lilly, Janssen, Novartis, Pfizer, Speakers bureau: Merck, BMS, Pfizer, Walter P Maksymowych Grant/research support from: Received research and/or educational grants from Abbvie, Novartis, Pfizer, UCB, Consultant of: WPM is Chief Medical Officer of CARE Arthritis Limited, has received consultant/participated in advisory boards for Abbvie, Boehringer, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, UCB, Speakers bureau: Received speaker fees from Abbvie, Janssen, Novartis, Pfizer, UCB., Sasha Bernatsky: None declared

AB0337 TOFACITINIB MONOTHERAPY OR COMBINED WITH METHOTREXATE IN PATIENTS WITH RHEUMATOID ARTHRITIS SHOW SIMILAR RETENTION OVER FOUR YEARS. REPORT FROM RHUMADATA ®

Background:

Since the introduction of biologic agents around the turn of the century, the scientific evidence shows that the majority of agents, independent of the therapeutic target, have a better outcome when used in combination with methotrexate (MTX). In 2014, tofacitinib (TOFA), an agent targeting Janus kinase 1 and 3, has reached the Canadian market with data showing that the combination with MTX may not be necessary [1,2].

Objectives:

To evaluate the efficacy and retention rate of TOFA in real-world patients with rheumatoid arthritis (RA).

Methods:

Two cohorts of patients prescribed TOFA was created. The first cohort was formed of patients who were receiving MTX concomitantly with TOFA (COMBO) and the other of patients using TOFA in monotherapy (MONO). MONO patients either never use MTX or were prescribed MTX post-TOFA initiation for at most 20% of the time they were on TOFA. COMBO patients received MTX at the time of TOFA initiation or were prescribed MTX post-TOFA initiation for at least 80% of the time. For all those patients, baseline demographic data definitions. Disease activity score and HAQ-DI were compared from the initiation of TOFA to the last visit. Time to medication discontinuation was extracted, and survival was estimated using Kaplan-Meier calculation for MONO and COMBO cohorts.

Results:

Overall, 194 patients were selected. Most were women (83%) on average younger than the men (men: 62.6 ± 11.0 years vs. women: 56.9 ± 12.1 years, p-value=0.0130). The patient’s assessments of global disease activity, pain and fatigue were respectively 5.0 ± 2.7, 5.2 ± 2.9, 5.1 ± 3.1 in the COMBO group and 6.2 ± 2.5, 6.5 ± 2.6, 6.3 ± 2.8 in the MONO group all differences being significant across groups. HAQ-DI at treatment initiation was 1.3 ± 0.7 and 1.5 ± 0.7 in the COMBO and MONO groups, respectively, p-value=0.0858. Similarly, the SDAI score at treatment initiation was 23.9 ± 9.4 and 25.2 ± 11.5, p-value=0.5546. Average changes in SDAI were -13.4 ± 15.5 (COMBO) and -8.9 ± 13.5 (MONO), p-value=0.1515, and changes in HAQ -0.21 ± 0.63 and -0.26 ± 0.74, p-value 0.6112. At treatment initiation, DAS28(4)ESR were 4.4 ± 1.4 (COMBO) and 4.6 ± 1.3 (MONO), p-value 0.5815, with respective average changes of -1.06 ± 2.07 and -0.70 ± 1.96, p-value=0.2852. The Kaplan-Meier analysis demonstrated that the COMBO and MONO retention curves were not statistically different (log-rank p-value=0.9318).

Conclusion:

Sustainability of TOFA in MONO or COMBO are not statistically different as are the changes in DAS28(4)ESR and SDAI. Despite this result, some patients may still benefit from combination with MTX.

References:

[1]Product Monograph - XELJANZ ® (tofacitinib) tablets for oral administration Initial U.S. Approval: 2012.

[2] Reed GW, Gerber RA, Shan Y, et al. Real-World Comparative Effectiveness of Tofacitinib and Tumor Necrosis Factor Inhibitors as Monotherapy and Combination Therapy for Treatment of Rheumatoid Arthritis [published online ahead of print, 2019 Nov 9].Rheumatol Ther. 2019;6(4):573–586. doi:10.1007/s40744-019-00177-4.

Disclosure of Interests:

Denis Choquette Grant/research support from: Rhumadata is supported by grants from Pfizer, Amgen, Abbvie, Gylead, BMS, Novartis, Sandoz, eli Lilly,, Consultant of: Pfizer, Amgen, Abbvie, Gylead, BMS, Novartis, Sandoz, eli Lilly,, Speakers bureau: Pfizer, Amgen, Abbvie, Gylead, BMS, Novartis, Sandoz, eli Lilly,, Louis Bessette Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Sanofi, Loïc Choquette Sauvageau: None declared, Isabelle Ferdinand Consultant of: Pfizer, Abbvie, Amgen, Novartis, Speakers bureau: Pfizer, Amgen, Boulos Haraoui Grant/research support from: Abbvie, Amgen, Pfizer, UCB, Grant/research support from: AbbVie, Amgen, BMS, Janssen, Pfizer, Roche, and UCB, Consultant of: Abbvie, Amgen, Lilly, Pfizer, Sandoz, UCB, Consultant of: AbbVie, Amgen, BMS, Celgene, Eli Lilly, Janssen, Merck, Pfizer, Roche, and UCB, Speakers bureau: Pfizer, Speakers bureau: Amgen, BMS, Janssen, Pfizer, and UCB, Frédéric Massicotte Consultant of: Abbvie, Janssen, Lilly, Pfizer, Speakers bureau: Janssen, Jean-Pierre Pelletier Shareholder of: ArthroLab Inc., Grant/research support from: TRB Chemedica, Speakers bureau: TRB Chemedica and Mylan, Jean-Pierre Raynauld Consultant of: ArthroLab Inc., Marie-Anaïs Rémillard Consultant of: Abbvie, Amgen, Eli Lilly, Novartis, Pfizer, Sandoz, Paid instructor for: Abbvie, Amgen, Eli Lilly, Novartis, Pfizer, Sandoz, Speakers bureau: Abbvie, Amgen, Eli Lilly, Novartis, Pfizer, Sandoz, Diane Sauvageau: None declared, Édith Villeneuve Consultant of: Abbvie, Amgen, BMS, Celgene, Pfizer, Roche, Sanofi-Genzyme,

UCB, Paid instructor for: Abbvie, Speakers bureau: AbbVie, BMS, Pfizer, Roche, Louis Coupal: None declared

How cost-effective is the treatment of dyslipidemia in patients with diabetes but without cardiovascular disease?

OBJECTIVE

Epidemiological studies have shown that the risk of myocardial infarction (MI) in diabetic patients without cardiovascular disease (CVD) is comparable to the risk of MI in patients with CVD. We used a validated Markov model to compare the long-term costs and benefits of treating dyslipidemia in diabetic patients without CVD versus treating CVD patients without diabetes in the U.S. The generalizability and robustness of these results were also compared across six other countries (Canada, France, Germany, Italy, Spain, and the U.K.).

RESEARCH DESIGN AND METHODS

With use of the Cardiovascular Disease Life Expectancy Model, cost effectiveness simulations of simvastatin treatment were performed for men and women who were 40-70 years of age and had dyslipidemia. We forecast the long-term risk reduction in CVD events after treatment. On the basis of the Scandinavian Simvastatin Survival Study results, we assumed a 35% reduction in LDL cholesterol and an 8% rise in HDL cholesterol.

RESULTS

In the U.S., treatment with simvastatin for CVD patients without diabetes was cost-effective, with estimates ranging from $8,799 to $21,628 per year of life saved (YOLS). Among diabetic individuals without CVD, lipid therapy also appeared to be cost-effective, with estimates ranging from $5,063 to $23,792 per YOLS. In the other countries studied, the cost effectiveness of treating diabetes in the absence of CVD was comparable to the cost effectiveness of treating CVD in the absence of diabetes.

CONCLUSIONS

Among diabetic men and women who do not have CVD, lipid therapy is likely to be as effective and cost-effective as treating nondiabetic individuals with CVD.

Lipid screening to prevent coronary artery disease: a quantitative evaluation of evolving guidelines

BACKGROUND

There is strong evidence to support the treatment of abnormal blood lipid levels among people with cardiovascular disease. Primary prevention is problematic because many individuals with lipid abnormalities may never actually develop cardiovascular disease. We evaluated the 1998 Canadian lipid guidelines to determine whether they accurately identify high-risk adults for primary prevention.

METHODS

Using data from the Lipid Research Clinics and receiver operating characteristic (ROC) curves, we compared the diagnostic performance of the 1998 lipid guidelines when risk factors for coronary artery disease (CAD) were counted versus calculating risk using Framingham risk equations. We also compared the diagnostic accuracy of the 1998 guidelines with guidelines previously published by the National Cholesterol Education Program in the United States and the 1988 Canadian Consensus Conference on Cholesterol and then used Canadian Heart Health Survey data to forecast lipid screening and treatment rates for the Canadian population.

RESULTS

The Framingham risk equations were more accurate than counting risk factors for predicting CAD risk (areas under the ROC curves, 0.83 [standard deviation (SD) 0.02] v. 0.77 [SD 0.03], p < 0.05). Risk counting was a particularly poor method for predicting risk for women. The 1998 Canadian guidelines identified high-risk individuals more accurately than the earlier guidelines, but the increased accuracy was largely due to a lower false-positive rate or a higher true-negative rate (i.e., increased test specificity). Using the 1998 lipid guidelines we estimate that 5.9 million Canadians currently free of cardiovascular disease would be eligible for lipid screening and 322,705 (5.5%) would require therapy.

INTERPRETATION

Calculating risk using risk equations is a more accurate method to identify people at high risk for CAD than counting the number of risk factors present, especially for women, and the 1998 Canadian lipid screening guidelines are significantly better at identifying high-risk patients than the 1988 guidelines. Many of our findings were incorporated into the new 2000 guidelines.

Cost-effectiveness of treating hyperlipidemia in the presence of diabetes : who should be treated?

BACKGROUND

The objective of this study was to estimate the long-term costs and benefits of treating hyperlipidemia among diabetic patients with and without known cardiovascular disease after validating the Cardiovascular Life Expectancy Model.

METHODS AND RESULTS

The model estimates were compared with the Scandinavian Simvastatin Survival Study (4S) and used to estimate the long-term costs and benefits of treatment with simvastatin. Simulations were performed for men and women, 40 to 70 years of age, having pretreatment LDL cholesterol values of 5.46, 4.34, and 3.85 mmol/L (211, 168, and 149 mg/dL). We forecasted the long-term risk of cardiovascular events, the need for medical and surgical interventions, and the associated costs in 1996 US dollars. The model validated well against the observed results of the of the 4S diabetic patients. In this validation, the model estimates fell within the 95% confidence interval of the observed results for 7 of the 8 available end points (coronary deaths, total deaths, and so forth). Treatment with simvastatin for patients with cardiovascular disease is cost-effective for men and women, with or without diabetes. Among diabetic individuals without cardiovascular disease, the benefits of primary prevention were also substantial and the cost-effectiveness ratios attractive across a wide range of assumptions ( approximately $4000 to $40 000 per year of life saved). These conclusions were robust even among diabetics with lower baseline LDL values and smaller LDL reductions as observed in the Cholesterol and Recruitment Events (CARE) trial.

CONCLUSIONS

Among adults with hyperlipidemia, the presence of diabetes identifies men and women among whom lipid therapy is likely to be effective and cost-effective even in the absence of other risk factors or known cardiovascular disease.

The cost-effectiveness of exercise training for the primary and secondary prevention of cardiovascular disease

BACKGROUND

Although exercise training improves cardiovascular disease (CVD) risk factors, few studies have evaluated its potential long-term cost-effectiveness.

METHODS

Using the Cardiovascular Disease Life Expectancy Model, a validated disease simulation model, we calculated the life expectancy of average 35- to 74-year-old Canadians found in the 1992 Canadian Heart Health Survey. The impacts of exercise training on cardiovascular risk factors were estimated as a 4% decrease in low-density lipoprotein (LDL) cholesterol, a 5% increase in high-density lipoprotein (HDL) cholesterol, and a 6 mm Hg decrease in both systolic and diastolic blood pressure. Exercise adherence was estimated at 50% for the first year and 30% for all additional years. Costs for a supervised exercise program determined from Canadian sources and converted to US dollars were estimated at $605 for the first year (medical evaluation, stress test, exercise prescription, and program costs) and $367 for all additional years (program costs). For an unsupervised program, the costs were estimated at $311 for the first year and $73 for all additional years.

RESULTS

The cost-effectiveness (CE) of an unsupervised exercise program (1996 U.S. dollars) was less than $12,000 per year of life saved (YOLS) for all individuals. The CE of a supervised exercise program was less than $15,000/YOLS for men with CVD, and between $12,000 and $43,000 for women with CVD and men without CVD.

CONCLUSIONS

Given the relatively few risks, substantial long-term benefits, and modest costs, an unsupervised exercise training program represents good value for all. A more expensive supervised exercise program is also cost-effective for most individuals with CVD.

The clinical burden of prostate cancer in Canada: forecasts from the Montreal Prostate Cancer Model

OBJECTIVES

The incidence of prostate cancer is increasing, as is the number of diagnostic and therapeutic interventions to manage this disease. We developed a Markov state-transition model--the Montreal Prostate Cancer Model--for improved forecasting of the health care requirements and outcomes associated with prostate cancer. We then validated the model by comparing its forecasted outcomes with published observations for various cohorts of men.

METHODS

We combined aggregate data on the age-specific incidence of prostate cancer, the distribution of diagnosed tumours according to patient age, clinical stage and tumour grade, initial treatment, treatment complications, and progression rates to metastatic disease and death. Five treatments were considered: prostatectomy, radiation therapy, hormonal therapies, combination therapies and watchful waiting. The resulting model was used to calculate age-, stage-, grade- and treatment-specific clinical outcomes such as expected age at prostate cancer diagnosis and death, and metastasis-free, disease-specific and overall survival.

RESULTS

We compared the model's forecasts with available cohort data from the Surveillance, Epidemiology and End Results (SEER) Program, based on over 59,000 cases of localized prostate cancer. Among the SEER cases, the 10-year disease-specific survival rates following prostatectomy for tumour grades 1, 2 and 3 were 98%, 91% and 76% respectively, as compared with the model's estimates of 96%, 92% and 84%. We also compared the model's forecasts with the grade-specific survival among patients from the Connecticut Tumor Registry (CTR). The 10-year disease-specific survival among the CTR cases for grades 1, 2 and 3 were 91%, 76% and 54%, as compared with the model's estimates of 91%, 73% and 37%.

INTERPRETATION

The Montreal Prostate Cancer Model can be used to support health policy decision-making for the management of prostate cancer. The model can also be used to forecast clinical outcomes for individual men who have prostate cancer or are at risk of the disease.

The economic burden of prostate cancer in Canada: forecasts from the Montreal Prostate Cancer Model

BACKGROUND

We developed an economic model of prostate cancer management from diagnosis until death. We have used the Montreal Prostate Cancer Model to estimate the total economic burden of the disease in a cohort of Canadian men.

METHODS

Using this Markov state-transition simulation model, we estimated the probability of prostate cancer, annual prostate cancer progression rates and associated direct medical costs according to patient age, tumour stage and grade, and treatment modalities in a 1997 cohort of Canadian men. The estimated lifetime costs of prostate cancer included the costs of clinical staging, initial treatments and complications, follow-up cancer therapies, routine outpatient care, and palliative care following metastatic disease.

RESULTS

The clinical burden of prostate cancer forecasted using the model was similar to the projections of the National Cancer Institute. In the 1997 cohort of 5.8 million Canadian men between 40 and 80 years old, prostate cancer would be diagnosed in an estimated 701,491 men (12.1%) over their lifetime. Direct medical costs would total $9.76 billion, or $3.89 billion when discounted 5% annually.

INTERPRETATION

The Montreal Prostate Cancer Model indicates that the economic burden of prostate cancer to Canada's health care system will be substantial. Further analyses are needed to identify the most efficient means of treating this disease.

Impact of treating hyperlipidemia or hypertension to reduce the risk of death from coronary artery disease

OBJECTIVE

To compare the prevalence of modifiable risk factors for cardiovascular disease among hypertensive and nonhypertensive adults and to estimate the effect of treating hyperlipidemia or hypertension to reduce the risk of death from coronary artery disease.

METHODS

The authors evaluated a sample of 7814 subjects aged 35-74 years free of clinical cardiovascular disease from the Canadian Heart Health Surveys to estimate the prevalence of cardiovascular risk factors. They identified hyperlipidemic subjects (ratio of total cholesterol to high-density lipoprotein cholesterol [total-C/HDL-C] 6.0 [corrected] or more for men and 5.0 [corrected] or more for women) and hypertensive subjects (systolic or diastolic blood pressure 160/90 mm Hg or greater, or receiving pharmacologic or nonpharmacologic treatment). A life expectancy model was used to estimate the rate of death from coronary artery disease following specific treatments.

RESULTS

An elevated total-C/HDL-C ratio was significantly more common among hypertensive than nonhypertensive men aged 35-64 (rate ratio [RR] 1.56 for age 35-54, 1.28 for age 55-64) and among hypertensive than nonhypertensive women of all ages (RR 2.73 for age 35-54, 1.58 for age 55-64, 1.31 for age 65-74). Obesity and a sedentary lifestyle were also more common among hypertensive than among nonhypertensive subjects. According to the model, more deaths from coronary artery disease could be prevented among subjects with treated but uncontrolled hypertension by modifying lipids rather than by further reducing blood pressure for men aged 35-54 (reduction of 50 v. 29 deaths per 100,000) and 55-64 (reduction of 171 v. 104 deaths per 100,000) and for women aged 35-54 (reduction of 44 v. 39 deaths per 100,000). Starting antihypertensive therapy in subjects aged 35-74 with untreated hypertension would achieve a greater net reduction in deaths from coronary artery disease than would lipid lowering. Nonetheless, the benefits of lipid therapy were substantial: lipid intervention among hypertensive subjects aged 35-74 represented 36% of the total benefits of treating hyperlipidemia in the total hyperlipidemic population.

INTERPRETATION

The clustering of hyperlipidemia and the potential benefits of treatment among hypertensive adults demonstrate the need for screening and treating other cardiovascular risk factors beyond simply controlling blood pressure.

Cost-effectiveness of 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors in the secondary prevention of cardiovascular disease: forecasting the incremental benefits of preventing coronary and cerebrovascular events

OBJECTIVE

To forecast the long-term benefits and cost-effectiveness of lipid modification in the secondary prevention of cardiovascular disease.

METHODS

A validated model based on data from the Lipid Research Clinics cohort was used to estimate the benefits and cost-effectiveness of lipid modification with 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins) based on results from the Scandinavian Simvastatin Survival Study (4S), including a 35% decrease in low-density-lipoprotein (LDL)-cholesterol levels and an 8% increase in high-density-lipoprotein (HDL)-cholesterol levels. After comparing the short-term outcomes predicted for the 4S with the results actually observed, we forecast the long-term risk of recurrent myocardial infarction, congestive heart failure, transient ischemic attacks, arrhythmias, and strokes and the need for surgical procedures such as coronary artery bypass grafting, catheterization, angioplasty, and pacemaker insertions. Outpatient follow-up care costs were estimated, as were the costs of hospital care and drug therapy. All costs were expressed in 1996 US dollars.

RESULTS

The short-term outcomes predicted for the 4S were consistent with the observed results. The long-term benefits of lipid modification among low-risk subjects (normotensive nonsmokers) with a baseline LDL/ HDL ratio of 5 but no other risk factors ranged from $5424 to $9548 per year of life saved for men and $8389 to $13747 per year of life saved for women. In high-risk subjects (hypertensive smokers) with an LDL/HDL ratio of 5, the estimated costs ranged from $4487 to $8532 per year of life saved in men and $5138 to $8389 per year of life saved in women. Assuming that lipid modification has no effect on the risk of stroke, cost-effectiveness increased by as much as 100%.

CONCLUSIONS

These long-term cost estimates are consistent with the short-term economic analyses of the published 4S results. The long-term treatment of hyperlipidemia in secondary prevention is forecasted to be cost-effective across a broad range of patients between 40 and 70 years of age. Recognizing the additional effects of lipid changes on cerebrovascular events can substantially improve the cost-effectiveness of treating hyperlipidemia.

Estimating the benefits of modifying risk factors of cardiovascular disease: a comparison of primary vs secondary prevention

OBJECTIVES

To compare the potential years of life saved (YOLS) associated with risk factor modification in the primary and secondary prevention of cardiovascular disease (CVD).

METHODS

The CVD life expectancy model estimates the risk of death due to coronary disease, stroke, and other causes based on the levels of independent risk factors (such as age, blood pressure, and blood lipid levels) found in the cohort of the Lipid Research Clinics. The model was validated by comparing its predictions with the observed fatal outcomes of 9 randomized clinical trials. We then estimated the YOLS associated with treating hyperlipidemia or hypertension among hypothetical patient groups with and without CVD at baseline. We defined high-risk patients as those with 3 risk factors (hyperlipidemia, cigarette smoking, and hypertension) and low-risk patients as those with isolated hypertension or hyperlipidemia.

RESULTS

The fatal events predicted by the model were consistent with the clinical trial results. Among men and women with hyperlipidemia without CVD, the forecasted benefits of lipid therapy were substantially greater among high-risk groups vs low-risk groups (4.74-0.78 YOLS vs 2.50-0.25 YOLS, respectively). Among those with CVD, the forecasted benefits of treatment were similar for both high-risk and low-risk groups (4.65-0.65 YOLS vs 3.84-0.58 YOLS, respectively). The results for hypertension therapy also demonstrated greater benefits for high-risk vs low-risk patients undergoing primary prevention therapy (1.34-0.29 YOLS vs 0.85-0.13 YOLS, respectively), and the forecasted benefits in secondary prevention were similar (1.26-0.23 YOLS vs 1.00-0.23 YOLS, respectively).

CONCLUSIONS

The clinical approach to risk factor modification in primary prevention should be different from that in secondary prevention. The forecasted benefits of therapy among patients without CVD are greatest in the presence of other risk factors. Among those with CVD, the benefits of therapy are equivalent, thereby obviating the need to target high-risk patients.

Identifying adults at increased risk of coronary disease. How well do the current cholesterol guidelines work?

OBJECTIVE

To assess the accuracy of lipid screening strategies to identify individuals at increased risk of coronary heart disease mortality.

PATIENTS

The 15% random sample of adults recruited into the Lipid Research Clinic Prevalence and Follow-up Studies, which included 3678 men and women aged 35 to 74 years. Total plasma cholesterol levels, lipoprotein fractions, and other coronary risk factors at study entry were compared with subsequent coronary heart disease mortality (mean follow-up, 12.2 years).

MAIN OUTCOME MEASURES

The areas under receiver operating characteristic curves for blood lipids, lipid ratios, the screening guidelines proposed by the National National Cholesterol Education Program, those of the Canadian Consensus Conference on Cholesterol, and a coronary risk model that used Framingham data.

MAIN RESULTS

The current National Cholesterol Education Program guidelines (area under the curve, 0.74) were significantly (P = .03) more accurate than the old National Cholesterol Education Program guidelines (area, 0.72). The ratio of total plasma cholesterol level to high-density lipoprotein cholesterol level (area, 0.72) was as accurate as current National Cholesterol Education Program guidelines. The coronary risk model (area, 0.85) was superior (P < .003) to all other screening maneuvers. Compared with the current National Cholesterol Education Program guidelines, the risk model demonstrated superior test sensitivity (70% vs 45%) with only slightly reduced specificity (82% vs 86%).

CONCLUSION

The ratio of total plasma cholesterol level to high-density lipoprotein cholesterol level is as accurate as current American screening guidelines. Future guidelines should better incorporate high-density lipoprotein cholesterol levels and nonlipid risk factors to target high-risk individuals accurately.

The cost-effectiveness of HMG-CoA reductase inhibitors to prevent coronary heart disease. Estimating the benefits of increasing HDL-C

OBJECTIVE

To evaluate the lifetime cost-effectiveness of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors for treatment of high blood cholesterol levels.

DESIGN

We added cost data to a validated coronary heart disease (CHD) prevention computer model that estimates the benefits of lifelong risk factor modification. The updated model takes into account the costs of cholesterol reduction, the savings in CHD health care costs attributable to intervention, the additional non-CHD costs resulting from patients' living longer, and the beneficial effects of reducing CHD risk by reducing total cholesterol and increasing high-density lipoprotein cholesterol (HDL-C).

PATIENTS

Men and women aged 30 to 70 years who were free of CHD, had total cholesterol levels equal to the 90th percentile of the US distribution in their age and sex group, had HDL-C levels equal to the mean of the US distribution in their age and sex group, and were either with or without additional CHD risk factors.

INTERVENTION

Use of 20 mg of lovastatin per day, which on average reduces total serum cholesterol by 17% and increases HDL-C by 7%.

MAIN OUTCOME MEASURES

Cost per year of life saved after discounting benefits and costs by 5% annually.

RESULTS

The increase in HDL-C associated with lovastatin lowered cost-effectiveness ratios by approximately 40%, such that the treatment of hypercholesterolemia was relatively cost-effective for men (as low as $20,882 per year of life saved at age 50 years) and women ($36,627 per year of life saved at age 60 years) with additional risk factors. Non-CHD costs resulting from longer life expectancy after intervention added at most 23% to the cost-effectiveness ratios for patients who began treatment at age 70 years, and as little as 3% for patients at age 30 years.

CONCLUSION

The cost-effectiveness of HMG-CoA reductase inhibitors varied widely by age and sex and was sensitive to the presence of non-lipid CHD risk factors. The additional non-CHD costs due to increased life expectancy may be significant for the elderly. Accounting for the drug effects of raising HDL-C levels increased the proportion of the population for which medication treatment was relatively cost-effective.

Bayesian estimation of disease prevalence and the parameters of diagnostic tests in the absence of a gold standard

It is common in population screening surveys or in the investigation of new diagnostic tests to have results from one or more tests investigating the same condition or disease, none of which can be considered a gold standard. For example, two methods often used in population-based surveys for estimating the prevalence of a parasitic or other infection are stool examinations and serologic testing. However, it is known that results from stool examinations generally underestimate the prevalence, while serology generally results in overestimation. Using a Bayesian approach, simultaneous inferences about the population prevalence and the sensitivity, specificity, and positive and negative predictive values of each diagnostic test are possible. The methods presented here can be applied to each test separately or to two or more tests combined. Marginal posterior densities of all parameters are estimated using the Gibbs sampler. The techniques are applied to the estimation of the prevalence of Strongyloides infection and to the investigation of the diagnostic test properties of stool examinations and serologic testing, using data from a survey of all Cambodian refugees who arrived in Montreal, Canada, during an 8-month period.

Life expectancy following dietary modification or smoking cessation. Estimating the benefits of a prudent lifestyle

OBJECTIVE

To evaluate the maximum benefits of dietary modification or smoking cessation to the life expectancy of North American adults.

DESIGN

Using a computer model, we estimated the change in life expectancy for men and women following risk factor modification. We then estimated the total number of adults who would be targeted by national guidelines and the total person-years of life that would be saved.

PATIENTS

Men and women aged 30 to 74 years who were free of coronary heart disease.

INTERVENTIONS

Smoking cessation or serum cholesterol-reducing diets with 8% to 10% saturated fat and 240 to 300 mg of daily cholesterol, respectively.

RESULTS

On average, dietary modification would reduce serum cholesterol levels from 0.45 mmol/L (17.4 mg/dL) to 0.75 mmol/L (29.1 mg/dL) in men and 0.12 mmol/L (4.6 mg/dL) to 0.55 mmol/L (21.4 mg/dL) in women, thereby increasing life expectancy by 0.03 to 0.4 year and 0.01 to 0.16 year, respectively. Smoking cessation would increase life expectancy from 2.59 to 4.43 years among men and from 2.6 to 3.68 years among women. Among adult Canadians, dietary modification would save 373,000 to 683,000 person-years of life. The majority of these benefits would occur among men who start dieting at ages 30 to 59 years. Smoking cessation would add more than 4 million person-years of life to the Canadian population. The relative impact of either intervention among American adults would be similar to these Canadian estimates.

CONCLUSIONS

Younger men, aged 30 to 59 years, might live slightly longer after dietary change, but among women and older men the average benefits would be negligible. The benefits of smoking cessation are more uniform across age and sex and are substantially greater than those predicted for dietary change.

Risk-benefit assessment of drug treatment to prevent coronary heart disease. Estimating the benefits of risk factor modification

Risk factor modification to prevent the development of coronary heart disease (CHD) is a rapidly growing concern of physicians interested in disease prevention. Drug treatments to reduce hypertension and hyperlipidaemia are 2 important interventions for CHD primary prevention. The benefits of these interventions have been demonstrated in short term clinical trials by reducing the incidence of stroke and coronary events. While the short term benefits may appear modest, the long term changes in life expectancy and disease morbidity may be substantial for carefully targeted groups of patients. Computer models are therefore increasingly being used to estimate the long term benefits of risk factor modification among selected patients. A review of published CHD models demonstrates that predictions among the different models are usually consistent. Moreover, the results of randomised clinical trials can be accurately forecasted using the CHD Primary Prevention Model.

Serum lipid screening to identify high-risk individuals for coronary death. The results of the Lipid Research Clinics prevalence cohort

OBJECTIVE

To assess the accuracy of specific plasma lipid fractions in predicting coronary heart disease (CHD) mortality among adults.

METHODS

Follow-up data for a random sample of 30- to 79-year-old men and women recruited into the Lipid Research Clinics Prevalence and Follow-up Studies were included in this analysis (n = 4499). Baseline measurements of total plasma cholesterol and lipoprotein fractions were compared with subsequent CHD mortality after a mean follow-up of 12.3 years. The areas under receiver operating characteristics curves for specific serum lipids were compared for individuals aged 30 to 59 and 60 to 79 years.

MAIN RESULTS

For the younger cohort, the ratio of total cholesterol to high-density lipoprotein cholesterol was a better predictor (P < .05) of CHD mortality (receiver operating characteristic curve area, 0.80 +/- 0.03) than was total cholesterol level alone (receiver operating characteristic curve area, 0.73 +/- 0.03) or any other single lipoprotein measurement. Among the older cohort, the same screening strategies performed poorly, with receiver operating characteristic curve areas ranging from 0.51 +/- 0.05 for total cholesterol to 0.64 +/- 0.05 for the ratio of low-density to high-density lipoprotein cholesterol levels.

CONCLUSION

Plasma lipid levels are poor predictors of coronary death among those aged 60 to 79 years without known CHD. These data indicate the need to define better lipid screening strategies for older, asymptomatic adults. Among younger adults aged 30 to 59 years, high-density lipoprotein cholesterol measurement should be included as part of any lipid screening program, as the ratio of total to high-density lipoprotein cholesterol levels is the best lipid screening test to identify those at high risk for subsequent CHD mortality.

Economic impact of HIV infection and coronary heart disease in immigrants to Canada

OBJECTIVE

To compare the direct health care costs of illnesses associated with the human immunodeficiency virus (HIV) and of coronary heart disease (CHD) in immigrants to Canada.

DESIGN

Comparative cost analysis.

PARTICIPANTS

All people who immigrated to Canada in 1988. The numbers with HIV infection and CHD were estimated from country-specific HIV seroprevalence data and national CHD mortality statistics and data from the Framingham study. Health care costs, projected over the 10 years after immigration, were calculated on the basis of data from the Hospital Medical Records Institute and provincial fee schedules.

RESULTS

Of the 161,929 immigrants in 1988, 484 were estimated to be HIV positive. The total cost of treatment of HIV-related illnesses from 1989 to 1998 (discounted at 3%) would be $18.5 million: $17.1 million would be spent on the outpatient and inpatient care of the HIV-positive immigrants, $1.0 million on care of the subsequently infected sexual partners and $0.4 million on care of the HIV-positive children born to seropositive immigrant women. In comparison, CHD would develop in 2558 immigrants during the same 10-year period. The total CHD costs would be $21.6 million: $8.4 million would be spent on treating myocardial infarction, $3.2 million on coronary artery bypass grafting, $1.6 million on pacemaker insertion and $8.4 million on treating other CHD events.

CONCLUSIONS

The economic impact of HIV infection in immigrants to Canada is similar to that of CHD. This comparison identifies an important shortcoming in current immigration policy: economic considerations can be arbitrarily applied to certain diseases, thereby discriminating against specific groups of immigrants.

The clinical utility of serum lactate dehydrogenase in diagnosing pneumocystis carinii pneumonia among hospitalized AIDS patients

It has been previously demonstrated that serum lactate dehydrogenase is elevated among HIV patients with pneumocystis carinii pneumonia (PCP). To evaluate the clinical utility of this test we analyzed the admission LDH levels of patients hospitalized for the first time due to the secondary complications of AIDS. Among 76 patients without a prior history of PCP, 41 (54%) had PCP diagnosed during their hospitalization while 35 (46%) did not have PCP. Serum LDH was significantly higher among PCP patients than in patients without PCP (mean = 423 IU/L vs 234 IU/L). Receiver operating characteristic curve analysis demonstrated that at an optimal cutoff point of LDH greater than or equal to 240 IU/L, the test sensitivity and specificity were 0.78 and 0.74 respectively among all hospitalized patients. However, when only patients with dyspnea were considered, the optimal test sensitivity and specificity improved to 0.94 and 0.78 at a cutoff point of LDH greater than or equal to 220 IU/L. Comparing the areas under fitted ROC curves, serum LDH was a significantly better discriminator among patients with dyspnea than among those who were not short of breath. We conclude that while serum LDH is strongly associated with the presence of PCP among AIDS patients, it is a poor screening test for PCP when applied to all hospitalized AIDS patients with and without respiratory complaints. Serum LDH is no substitute for appropriate microbiological studies. However, with further evaluation, it may prove to be a useful test in guiding the clinical management of dyspneic patients in whom sputum or bronchial examinations are negative or not immediately available.

The benefits of treating hyperlipidemia to prevent coronary heart disease. Estimating changes in life expectancy and morbidity

OBJECTIVE

To evaluate the lifetime benefits of reducing total serum cholesterol levels to prevent coronary heart disease (CHD).

DESIGN

We developed a CHD primary prevention computer model to estimate the benefits associated with lifelong risk factor modification. We validated the model by comparing the computer estimates with the observed results of three primary CHD prevention trials.

PATIENTS

Men and women age 35 to 65 years who are free of CHD, with total serum cholesterol levels ranging from 5.2 to 7.8 mmol/L (200 to 300 mg/dL), with or without additional CHD risk factors.

INTERVENTIONS

Serum cholesterol reduction through dietary modification or diet and medications.

MAIN OUTCOME MEASURES

Changes in life expectancy and the delay of symptomatic CHD.

RESULTS

The computer forecasts for CHD end points closely matched the observed results of the Lipid Research Clinics Trial, the Helsinki Heart Study, and MRFIT. We then applied the computer model to low-risk and high-risk men and women with total serum cholesterol levels between 5.2 and 7.8 mmol/L (200 and 300 mg/dL) and estimated that, after reducing serum cholesterol levels 5% to 33%, the average life expectancy would increase by 0.03 to 3.16 years. We also forecast that the average onset of symptomatic CHD would be delayed among these patient groups by 0.06 to 4.98 years.

CONCLUSION

We conclude that this computer model accurately estimates the results of clinical trials and can be used to forecast the changes in life expectancy and morbidity (the development of CHD) associated with specific CHD risk reduction interventions. The wide variation surrounding these estimates underscores the need to better define which groups of individuals will gain the most from cholesterol reduction.

The bedside assessment of splenic enlargement

STUDY OBJECTIVE

To evaluate the clinical assessment of splenic enlargement using specific bedside maneuvers including Traube's space percussion, the splenic percussion sign, Middleton's maneuver, supine palpation, and right lateral decubitus palpation.

DESIGN

Quasi-experimental prospective study of cases and controls selected according to the results of abdominal ultrasonographic examinations.

SETTING

Selected inpatients of a tertiary care hospital.

MAIN RESULTS

Comparing the areas under the receiver operating characteristic curves for each bedside maneuver demonstrated that Traube's space percussion and palpation were significant discriminators (p less than 0.001) of splenic enlargement with respective areas of 0.70 +/- 0.04 and 0.76 +/- 0.04. No one palpation maneuver was superior to another, and right lateral decubitus palpation was not useful when performed after supine palpation. The splenic percussion sign (sensitivity 79%, specificity 46%) was no better than Traube's space percussion (sensitivity 62% and specificity 72%) in assessing splenic enlargement. The palpation maneuvers appeared more sensitive and more specific than Traube's space percussion. Palpation was a significant clinical discriminator when performed on patients who exhibited percussion dullness of Traube's space (area = 0.87 +/- 0.04, p less than 0.0001) but was of little value among those without percussion dullness (area = 0.55 +/- 0.08). Also, palpation was significantly more accurate when performed on lean patients versus obese patients (areas = 0.83 +/- 0.04 versus 0.65 +/- 0.08, p less than 0.05). When a positive bedside examination was defined as positive palpation and positive percussion (concordant-positive), the combined test sensitivity and specificity were 46% and 97% respectively.

CONCLUSIONS

The optimal clinical assessment of splenic enlargement includes the percussion of Traube's space. If Traube's space is dull, palpation of the spleen is warranted. This assessment is most accurate in lean patients.

Seizure vs. syncope: measuring serum creatine kinase in the emergency department

OBJECTIVE

To determine the utility of serum creatine kinase measurement for diagnosing generalized tonic-clonic seizures in patients presenting to an emergency department with transient loss of consciousness.

DESIGN

Prospective evaluation of a diagnostic parameter. Retrospective data collection with blinded assignment to diagnostic groups.

SETTING

University teaching hospital.

PATIENTS

Sequential sample of 205 patients with transient loss of consciousness. The study group consisted of 96 patients who had creatine kinase measurements in the emergency department.

MEASUREMENTS AND MAIN RESULTS

An investigator blinded to the results of creatine kinase measurements retrospectively classified events into seizure and nonseizure groups on the basis of clinical presentation, prior history, and follow-up investigations. Mean (+/- SE) creatine kinase level was significantly higher in the seizure group (231.1 +/- 34.8 U/L vs. 70.5 +/- 5.6 U/L, p less than 0.001). Elevated creatine kinase had a test specificity of 0.98 (95% CI 0.90-1.00) and a sensitivity of 0.43 (95% CI 0.28-0.59). The discriminating power of creatine kinase elevation was directly related to the time interval between the event and testing (p less than 0.0001). Among samples taken more than three hours after the event, test sensitivity was 0.80 (0.52-1.00) and specificity was 0.94 (0.71-1.00).

CONCLUSION

Creatine kinase may be a useful test for evaluating patients with transient loss of consciousness. The test is highly specific for diagnosing generalized seizures in the emergency department. Test sensitivity improves by sampling serum at least three hours after the event.

Screening for hypercholesterolemia among Canadians: how much will it cost?

OBJECTIVE

To determine the cost of screening all Canadians aged 30 years or more without coronary heart disease (CHD) for hypercholesterolemia.

DATA SOURCES

The expected results of initial screening of the serum cholesterol level were estimated on the basis of 1986 Canadian census data and the 1978 Canada Health Survey. The results of repeat testing were estimated on the basis of data from the Lipid Research Clinics Prevalence Study. Lipid profile results were extrapolated from tests at the Montreal General Hospital's clinical chemistry laboratory. Laboratory costs and primary care practitioner costs were provided by the Canadian Society of Clinical Chemists and provincial fee schedules respectively.

MAIN RESULTS

Among 12,479,356 Canadians free of CHD 48.7% would be identified as being at high risk, 4.8% would be identified as being at moderate risk, and 46.6% would be reassured that their lipid risk for CHD was low. The total cost of implementing the program in the first year would be $432 million to $561 million ($325 million for laboratory tests and $107 million to $236 million for visits to primary care practitioners).

CONCLUSION

The substantial cost of implementing a nationwide screening program must be weighed against the expected benefits to ensure that the final result is both practical and economically feasible.

Splenic enlargement and Traube's space: how useful is percussion?

PURPOSE

The utility of Traube's space percussion in the bedside assessment of splenic enlargement was evaluated. The influence of meals and obesity on this sign were also assessed, because both are believed to interfere with the results of abdominal percussion.

PATIENTS AND METHODS

The inpatient population of a tertiary care hospital was studied where cases and controls were selected according to the results of abdominal ultrasonographic examinations.

RESULTS

Traube's space percussion exhibited a sensitivity of 0.62 (95% confidence interval [CI], 0.51 to 0.71) and a specificity of 0.72 (95% CI, 0.65 to 0.80) when classifying tympanitic examinations as negative. False-positive examinations were reduced by assessing patients more than two hours after mealtime. Obese patients were a source of false-negative examinations.

CONCLUSION

Traube's space percussion compares favorably with other commonly used clinical maneuvers and diagnostic tests. When performed alone in a selected patient population, it adds useful clinical information but is not sufficiently sensitive or specific to obviate the need for further diagnostic testing.

Delayed diagnosis of gynecologic tumors in elderly women: relation to national medical practice patterns

PURPOSE

To evaluate the hypothesis that less aggressive cancer screening practices might result in later diagnosis of cancer in the elderly, we analyzed the stage of diagnosis of tumors by age in the Connecticut Tumor Registry.

PATIENTS AND METHODS

Using Registry data from 1960 to 1975 and 1976 to 1983, we compared the proportion of tumors that were diagnosed at a localized stage among white women of various age groups. Thirteen specific tumor sites were analyzed, accounting for 55,688 tumors between 1960 and 1975 and 38,715 tumors between 1976 and 1983.

RESULTS

Only gynecologic cancers demonstrated a significant inverse relationship between the relative proportion of tumors that were diagnosed at a localized stage and advancing patient age during both time periods. Specifically, when the youngest women (aged 25 to 34) were compared with the oldest women (aged 85 and over), between 1960 and 1975, the relative proportion of localized cervical, uterine, and ovarian cancer dropped from 98 percent to 59 percent, 92 percent to 77 percent, and 59 percent to 27 percent, respectively. Similar declines were also seen between the intermediate-age groups, and data from 1976 to 1983 demonstrated identical age-related trends.

CONCLUSION

Our study reveals that the probability of diagnosing cancer of the cervix, uterus and ovaries at a localized and potentially curable stage decreases with advancing age. Published national health practice patterns demonstrated a similar age-related decline in gynecologic examinations and Pap smears even after adjustment for the exclusion of women who would have undergone previous hysterectomy. This decreasing use of gynecologic examinations may in part explain the age-related decline in localized gynecologic cancers.