Comparative effectiveness of first-line tumour necrosis factor inhibitor versus non-tumour necrosis factor inhibitor biologics and targeted synthetic agents in patients with rheumatoid arthritis: results from a large US registry study

Objectives

This study evaluated the comparative effectiveness of a tumour necrosis factor inhibitor (TNFi) versus a non-TNFi (biological disease-modifying antirheumatic drugs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs)) as the first-line treatment following conventional synthetic DMARDs, as well as potential modifiers of response, observed in US clinical practice.

Methods

Data were from a large US healthcare registry (Consortium of Rheumatology Researchers of North America Rheumatoid Arthritis Registry). The analysis included patients (aged ≥18 years) with a documented diagnosis of rheumatoid arthritis (RA), a valid baseline Clinical Disease Activity Index (CDAI) score of >2.8 and no prior bDMARD or tsDMARD use. Outcomes were captured at 1-year postinitiation of a TNFi (adalimumab, etanercept, certolizumab pegol, golimumab or infliximab) or a non-TNFi (abatacept, tocilizumab, rituximab, anakinra or tofacitinib) and included CDAI, 28-Joint Modified Disease Activity Score, patient-reported outcomes (including the Health Assessment Questionnaire Disability Index, EuroQol-5 Dimension score, sleep, anxiety, morning stiffness and fatigue) and rates of anaemia. Groups were propensity score-matched at baseline to account for potential confounding.

Results

There were no statistically significant differences observed between the TNFi and non-TNFi treatment groups for outcomes assessed, except the incidence rate ratio for anaemia, which slightly favoured the TNFi group (19.04 per 100 person-years) versus the non-TNFi group (24.01 per 100 person-years, p=0.03). No potential effect modifiers were found to be statistically significant.

Conclusions

The findings of no significant differences in outcomes between first-line TNF versus first-line non-TNF groups support RA guidelines, which recommend individualised care based on clinical judgement and consideration of patient preferences.

OP0275 REAL-WORLD CLINICAL BURDEN AND GLUCOCORTICOID USE IN PATIENTS WITH GIANT CELL ARTERITIS

Background:

Giant cell arteritis (GCA) is a rare form of vasculitis usually manifesting in people aged ≥50 yr and is more common in women. Symptoms include headache, jaw claudication, fatigue, polymyalgia; and blindness if untreated. While risks of complications can be reduced with promptly administered high-dose glucocorticoids (GC; 20-60 mg for 2-4 wk, then slowly tapered), further risks of high GC exposure and related complications over the course of therapy remain.

Objectives:

To compare GC use and GC-related complications in GCA patients (pts) vs a general population (GnP) cohort.

Methods:

This retrospective, observational cohort study was based on Optum’s de-identified Clinformatics®Data Mart Database (01/01/06-30/06/18, study period). The GCA cohort included pts with ≥1 inpatient or ≥2 outpatient claims ≥30 days apart with GCA-related diagnosis codes (ICD-9: 446.5x/ICD-10: M31.6x) between 01/01/06-30/06/17 (pt identification period) during which first occurrence of a GCA-related medical claim was set as index date (ID). The GnP cohort included pts without any medical claims for rheumatoid arthritis, GCA or polymyalgia rheumatica diagnosis codes during the study period, with their ID set as 12 mo from start of continuous health plan enrollment. Pts in both cohorts were required to be age ≥50 yr (on the ID) with continuous health plan enrollment ≥12 mo pre- and post-ID. Cohorts were 1:1 propensity score matched. GC use and incidence of GC-related complications were assessed from GC initiation, starting from the baseline period (12-mo pre-ID) to the end of GC use during the post-index period (ie the end of data availability, end of the study period, or death, whichever occurred first). Descriptive analyses included mean, standard deviation (SD) and median values for continuous variables, and frequency (n and %) for categorical variables. Continuous variables were compared between matched cohorts usingt-tests and Wilcoxon sum rank tests. Categorical variables were compared between matched cohorts using Chi-square tests or Fisher’s exact tests. Duration of GC use was analyzed using the Kaplan-Meier method and compared between matched cohorts using log-rank tests.

Results:

There were 6071 pts included in each of the GCA and matched GnP cohorts; median age per cohort was 76 yr, median Elixhauser comorbidity index score was 3.0, and the majority (~75%) were women. The median follow-up duration was 44 and 48 mo in the GCA and GnP cohorts, respectively. A higher proportion of pts in the GCA cohort than the GnP cohort (90.6 vs 63.8%;p<0.001) used GC. The mean (SD) duration of GC therapy was 230.5 (±326.8) days in the GCA cohort vs 36.3 (±107.2) days in the GnP cohort (p<0.001). Although the mean (SD) daily dose of GC (prednisone equivalent) was similar in both cohorts (27.6 [±28.20] vs 27.7 [±25.18] mg), the mean (SD) cumulative GC dose was significantly higher in the GCA cohort than the GnP cohort (3503.0 (±4622.6) mg vs 503.7 (±1593.51) mg;p<0.001). This indicates that GCA pts had chronic GC exposure over the study period while GnP pts likely utilized higher dose GC burst therapy less frequently. The number of incident complications associated with GC use were significantly greater in the GCA cohort, and included hypertension, diabetes, skin toxicity, infections, neuropsychiatric effects, gastrointestinal complications, ocular effects, and cardiovascular disease (p<0.05).

Conclusion:

The overall GC burden in pts with GCA is significantly higher than the general population and may result in downstream complications related to GC exposure. The incidence of GC-related complications was statistically significantly higher in GCA pts compared with GnP pts, even with a short duration of GC use. The early onset of these complications may be a significant contributor to long-term healthcare costs in GCA pts.

Acknowledgments:

Study and medical writing (provided by Gauri Saal, MA, Economics, Prime, Knutsford, UK, under the direction of authors) were funded by Sanofi, Inc.

Disclosure of Interests:

Rajeshwari Punekar Shareholder of: Sanofi, Employee of: Sanofi, Patrick LaFontaine Shareholder of: Sanofi, Employee of: Sanofi, John H. Stone Grant/research support from: Roche, Consultant of: Roche

OP0271 REAL-WORLD CLINICAL BURDEN AND GLUCOCORTICOID USE IN PATIENTS WITH POLYMYALGIA RHEUMATICA

Background:

Polymyalgia rheumatica (PMR) is a chronic inflammatory condition characterized by aching and morning stiffness in the neck, shoulders and pelvic girdle. It is a common inflammatory rheumatic disease in patients age >50 years, particularly women. While giant cell arteritis (GCA) is present in 9–21% of PMR cases, many PMR patients have symptoms independent of GCA. Current treatment options are limited to long-term glucocorticoid (GC), however, with risks of GC-related complications, including cardiovascular disease, osteoporosis, and diabetes mellitus.

Objectives:

To compare GC use and subsequent GC-related complications in patients with PMR vs a general population (GnP) cohort.

Methods:

This retrospective, observational cohort study was based on Optum’s de-identified Clinformatics®Data Mart Database (study period 01Jan2006-30June2018). The PMR cohort included patients with ≥1 inpatient or ≥2 outpatient claims ≥30 days apart with PMR related diagnosis codes (ICD-9: 725.xx or ICD-10: M35.3x) between 01Jan2006–30June2017 (patient identification period) during which first occurrence of a PMR-related medical claim was set as the index date (ID). Patients with ≥1 medical claim related to rheumatoid arthritis (RA) or GCA during the study period were excluded. The GnP cohort included patients without any RA, GCA or PMR diagnosis codes during the study period, with their ID set as 12 months from the start of continuous health plan enrollment. Patients in both cohorts were required to be age ≥50 years (on ID) with continuous health plan enrollment ≥12 months pre- and post-ID. Cohorts were 1:1 propensity score matched. GC use and incidence of GC-related complications were assessed from GC initiation, starting from the baseline period (12-months pre-ID) through to the end of GC use during the post-index period (i.e. the end of data availability, end of the study period or death [whichever occurred first]). Mean, standard deviation (SD) and median values for continuous variables, and frequency (n and %) for categorical variables were compared between the matched cohorts. Wilcoxon sum rank tests andt-tests on continuous variables and Chi-square tests or Fisher’s exact tests on categorical variables between matched cohorts were conducted. Duration of GC use was analyzed using the Kaplan-Meier method and compared between matched cohorts using log-rank tests.

Results:

In each of the PMR and GnP cohorts, 16,865 patients were included. In both matched cohorts, median age was 76 years, median Elixhauser comorbidity index score was 2.0, and the majority (~65%) were women. The median follow-up duration was 45 months and 51 months in the PMR and GnP cohorts, respectively. A higher proportion of patients in the PMR cohort than the matched GnP cohort (90.4% vs 62.8%;p<0.001) used GC. The mean (SD) duration of GC therapy was significantly longer in the PMR cohort than in the matched GnP cohort (242.1 [±317.2] days vs 35.5 [±124.6] days;p<0.001). Although patients in the PMR cohort had a lower average daily dose of GC (prednisone equivalent) vs the GnP cohort (mean [SD] mg 16.3 [± 21.9] vs 27.8 [±24.5], respectively [p<0.0001)], the cumulative GC dose was significantly higher in the PMR cohort than the GnP cohort (2125.4 [±3689.5] mg vs 476.6 [±1450.9] mg;p<0.001). This indicates PMR patients used chronic low dose GC while the GnP patients utilized higher dose GC burst therapy less frequently. The number of incident complications associated with GC use were significantly greater in the PMR cohort, and included hypertension, diabetes, skin toxicity, infections, neuropsychiatric effects, endocrine abnormalities, renal dysfunction/ failure, ocular effects, and cardiovascular disease (p<0.05).

Conclusion:

The overall GC burden in patients with PMR is high. With a higher incidence of GC-related comorbidities among PMR patients, early onset of these complications may be a significant contributor to long-term healthcare costs in these patients.

Acknowledgments:

This study was funded by Sanofi, Inc. Medical writing, under the direction of authors, was provided by Gauri Saal, MA Economics, Prime, Knutsford, UK, and funded by Sanofi.

Disclosure of Interests:

Rajeshwari Punekar Shareholder of: Sanofi, Employee of: Sanofi, Patrick LaFontaine Shareholder of: Sanofi, Employee of: Sanofi, John H. Stone Grant/research support from: Roche, Consultant of: Roche

Healthcare Utilization, Costs of Care, and Mortality Among Patients With Spinal Muscular Atrophy

Objectives: To understand treatment patterns, healthcare resource utilization, and costs of care among patients with spinal muscular atrophy (SMA). Methods: SMA patients were identified from a large managed care population using administrative claims data from January 2006 to March 2016. Patients were classified into infantile, childhood-onset, and late-onset groups based on age of first SMA diagnosis. They were matched 1:1 to non-SMA patients based on age, gender, geography, and health plan type. Results: In the infantile group, 17.4% and 26.1% were treated with invasive and non-invasive ventilation, respectively. Uses of orthotics/orthoses and orthopedic surgery were frequent: 54.5% and 22.7% childhood group; 27.0% and 38.5% late-onset group. Mean per member per month costs in SMA vs. matched non-SMA patients was $25,517 vs. $406 (infantile); $6,357 vs. $188 (childhood-onset); $2,499 vs. $742 (late-onset). Conclusions: SMA patients, particularly with infantile onset, incurred significantly higher healthcare utilization and costs than the general population.

Healthcare Utilization, Costs of Care, and Mortality Among Psatients With Spinal Muscular Atrophy

OBJECTIVES

To understand treatment patterns, healthcare resource utilization, and costs of care among patients with spinal muscular atrophy (SMA). Methods: SMA patients were identified from a large managed care population using administrative claims data from January 2006 to March 2016. Patients were classified into infantile, childhood-onset, and late-onset groups based on age of first SMA diagnosis. They were matched 1:1 to non-SMA patients based on age, gender, geography, and health plan type.

RESULTS

In the infantile group, 17.4% and 26.1% were treated with invasive and non-invasive ventilation, respectively. Uses of orthotics/orthoses and orthopedic surgery were frequent: 54.5% and 22.7% childhood group; 27.0% and 38.5% late-onset group. Mean per member per month costs in SMA vs. matched non-SMA patients was $25,517 vs. $406 (infantile); $6,357 vs. $188 (childhood-onset); $2,499 vs. $742 (late-onset).

CONCLUSIONS

SMA patients, particularly with infantile onset, incurred significantly higher healthcare utilization and costs than the general population.

Real-World Dose Modification Patterns of Subcutaneous Tocilizumab Among Patients with Rheumatoid Arthritis

BACKGROUND

The treatment of rheumatoid arthritis is based on the use of disease-modifying antirheumatic drugs (DMARDs). Tocilizumab can be used as monotherapy or in combination with conventional synthetic DMARDs for the treatment of moderate-to-severe active rheumatoid arthritis. Subcutaneous (SC) and intravenous forms of the drug are available, but the SC form is more widely used.

OBJECTIVE

To understand the real-world dose modification patterns of SC tocilizumab in the treatment of patients with rheumatoid arthritis in the United States.

METHODS

Data were obtained from the Truven (now IBM) MarketScan and Optum Clinformatics databases. Patients were included if they had ≥1 pharmacy claims for SC tocilizumab and met other inclusion criteria. The mean, standard deviation, and median values were reported for the continuous variables, and frequency was reported for the categorical variables. Kaplan-Meier analysis was used to analyze the time to first dose modification. Logistic regression modeling was used to identify predictors of the likelihood of dose modification.

RESULTS

The study included 1266 patients in the Truven database and 512 patients in the Optum database who had commercial or Medicare Advantage or supplemental insurance. Of the patients who started treatment with biweekly SC tocilizumab (48% each in the Truven and Optum databases), 37% in Truven and 40% in Optum had dose escalation to a weekly dose. Of those who started weekly SC tocilizumab (43% in the Truven and 49% in the Optum databases), 3% (Truven) and 4% (Optum) had dose reduction. The remaining patients started alternative SC tocilizumab doses. Overall, 60% and 68% of patients in the Truven and Optum cohorts, respectively, initiated or escalated to the higher weekly dose of tocilizumab; the mean time to dose escalation was 126 days and 112 days, respectively. In the Truven cohort, corticosteroid use, age, and anemia were the main predictors for dose escalation. In the Optum cohort, female patients had increased odds of dose escalation compared with male patients.

CONCLUSION

The dosing trends observed in this study show that physicians have taken advantage of the option to increase SC tocilizumab dosing, but only a few providers chose to reduce the dose. This trend in dose modification may increase the costs related to SC tocilizumab therapy.

Antidiabetic Activity of the Methanolic Extracts of Thuja occidentalis Twings in Alloxan-induced Rats

Objective and Background:

In hyperglycemic and alloxan-induced diabetic rats, the effect of Thuja occidentalis methanolic residue extract on blood glucose levels and some biochemical parameters were investigated.

Methods:

Significantly decreased blood glucose level by 22.85% and 27.66%, in hyperglycemic rats, respectively after 3 h, were seen in a single oral administration of the extract at a dose of 200 and 400 mg/kg. Blood glucose level was decreased by 50% in alloxan-induced diabetic rats within three weeks of daily treatment of Thuja occidentalis methanolic residue extract (200 and 400 mg/kg p.o). Alloxan-induced diabetic rats showed significant hypercholesterolemia in comparison with the control in alloxan induced rats.

Results:

In both normal and diabetic rats, there was also a significant decrease of elevated serum cholesterol and triglycerides. Hypertriglyceridemia was also shown to be prevented by treatment with plant extract (200 and 400mg/kg p.o) (p<0. 05). As compared with the control animals, diabetic control rats did not show any change in a level of creatinine and urea.

Conclusion:

Thuja occidentalis treatment may improve glucose homeostasis in alloxaninduced diabetes and alleviate kidney and liver function. Thuja occidentalis twigs could be a potential source of the new oral antidiabetic drug.

Differences in Health Care Use and Costs Among Patients With Cancer Receiving Intravenous Chemotherapy in Physician Offices Versus in Hospital Outpatient Settings

PURPOSE

The current shift in site of care from community oncology practices to the hospital outpatient department to deliver oncology services may have significant implications for the economic and clinical outcomes of cancer care. Therefore, this study compares health care use and costs among patients with cancer receiving intravenous (IV) chemotherapy in physician offices (PO) versus in hospital outpatient settings (HOP).

METHODS

This retrospective study, which was based on medical and pharmacy claims data, included patients (age, 18 to 64 years) initiating IV chemotherapy/biologic treatment between January 1, 2006, and August 31, 2012, who were diagnosed with early or metastatic breast cancer, metastatic lung cancer, metastatic colorectal cancer, or non-Hodgkin lymphoma or chronic lymphocytic leukemia. Patients were assigned to PO or HOP groups on the basis of where they received > 95% of their IV cancer therapy.

RESULTS

The study sample included 18,740 patients (12,899 PO; 5,841 HOP) who had a mean age of 51.6 years and a Deyo-Charlson Comorbidity Index score of 5.37. Overall office visits (21.8 ± 13.8 PO v 21.2 ± 12.9, P < .005) and outpatient services (50.8 ± 35.5 PO v 48.5 ± 33.6, P < .001) were higher in the PO group than in the HOP group. Cancer-related inpatient hospitalizations (0.6 ± 1.2 PO v 0.7 ± 1.4 HOP, P = .002) were lower in the PO group than in the HOP group. Although quality-of-care metrics were similar between the HOP and PO groups, follow-up all-cause costs ($82,773 PO v $122,473 HOP) and cancer-related health care costs ($69,037 PO v $108,177 HOP) were higher in the HOP group than in the PO group.

CONCLUSION

Despite similar resource use, all-cause and cancer-related health care costs in HOP were significantly higher compared with those in PO settings.

Medical expenditures of adult cancer survivors aged <65 years in the United States

BACKGROUND

To the authors' knowledge, this is the first study to provide national estimates of medical expenditures for all adult cancer survivors aged <65 years. Most studies of expenditures for cancer survivors in this age group have been based on the Medical Expenditure Panel Survey (MEPS) and were limited to "affected survivors."

METHODS

MEPS expenditure data for 2001 to 2007 were linked to data identifying all survivors from the National Health Interview Survey (NHIS), which is the MEPS sampling frame. The sample was comprised of adults ages 25 to 64 years. Propensity-score matching was used to estimate the effects of cancer on average total and out-of-pocket expenditures for all services and separately for prescriptions. Probit models were used to estimate effects on the probability of exceeding different expenditure thresholds.

RESULTS

Mean annual expenditures on all services in 2007 were $16,910 ± $3911 for survivors who were newly diagnosed with cancer, $7992 ± $972 for survivors who had been diagnosed in previous years, and $3303 ± $103 for other adults. Fifty-three percent of survivors were not identified in MEPS but only by linking to NHIS. Expenditures for all survivors averaged approximately $9300 compared with $13,600 for "affected survivors." For previously diagnosed survivors, the increase in mean expenditures attributable to cancer was approximately $4000 to $5000 annually. On average, relatively little of the increase was paid out of pocket, but cancer nearly doubled the risk of high out-of-pocket expenditures.

CONCLUSIONS

Previous MEPS analyses overstated average expenditures for all survivors. Nevertheless, the current results indicated that the increase in expenditures attributable to cancer is substantial, even for longer term survivors, and that cancer increases the relative risk of high out-of-pocket expenditures.