Using Biologics to Manage Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease that affects more than 1.3 million patients in the United States, most commonly beginning to effect people between the ages of 30 and 50 years, making it the most common autoimmune inflammatory arthritis in adults. It is characterized by inflammation of the synovial membranes and leads to progressive erosion and destruction of cartilage and bone tissue in the affected joints. RA can eventually affect your organs, such as eyes, skin, or lungs.

RA has a significant negative impact on the ability to perform daily activities and on health-related quality of life, conferring a substantial health care and economic burden. Costs attributable to RA are expected to further increase as the population ages and the prevalence of obesity and physical inactivity increases.¹

Evolving Therapy Options

Though RA is a complex disease, many advancements in treatment options have been developed in the last 30 years, including the increased use of biologics. There is no cure but with the right medications, many patients are able to completely control the symptoms.

Traditionally, treatment of RA uses disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, Janus kinase (JAK) inhibitors, and glucocorticoids. Common DMARDs include methotrexate (Rheumatrex, Trexall, Otrexup, Rasuvo), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine).² These drugs can slow the progression of joint damage associated with RA.

Janus kinase (JAK) inhibitors are another type of DMARD. People who cannot be treated with methotrexate alone may be prescribed a JAK inhibitor such as tofacitinib (Xeljanz) or baracitinib (Olumiant).²

Patients with more severe symptoms, however, are seeing success with medications called biologic response modifiers or biologic agents. FDA-approved drugs of this type include abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi) infliximab (Remicade), rituximab (Rituxan, MabThera), sarilumab (Kevzara) and tocilizumab (Actemra). Most often, patients take these drugs with methotrexate, as the mix of medicines is more helpful. ²

Weighing Treatment Decisions and Costs

“For patients newly diagnosed with RA, rapid initiation of 1 or more DMARDs, usually a conventional synthetic DMARD (csDMARD) such as methotrexate, is now regarded as the standard of care,” explained Natalie McCormick, PhD, Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, in a recent JAMA study invited commentary.³

“However, the threshold for initiating more costly biologic DMARD therapy is not as clear cut and has been influenced by sociodemographic, physician, and insurance coverage factors,” she continued.³

Dr McCormick’s commentary referred to a different study, conducted by researchers at the Univeristy of Toronto, in which the association of health insurance coverage in relation to the switch to biologics was measured.³

Results of that study show that prescription of the first biologic DMARD is a costly health care decision, with the choice to prescribe a biologic DMARD associated with large cost and clinical implications. Therefore, small changes in time to first biologic DMARD have major clinical and economic impacts.⁴

“Research on the initiation of the first biologic medication is often limited by small nonrepresentative samples and short follow-up periods, reducing the interpretability and generalizability of findings. In addition, prescriber decisions to switch to biologic DMARDs are often influenced by nonmedical reasons associated with a patient’s insurance coverage,” study authors explained.

The financial burden on health care systems due to biologic therapies is considerable. RA represented the fifth highest drug spend category for Medicare and for 7^th commercial payers in 2019, at $2.26 per member per year (PMPM) and $1.18 PMPM, respectively.⁵

Updated Recommendations

The European League Against Rheumatism (EULAR) taskforce published updated 2019 RA management recommendations based on the balance of clinical, functional and structural efficacy; safety; costs; and patients’ perceptions as evaluated by the task force.⁶

Majority of recommendations remain unchanged but EULAR noted that the ongoing development of new bDMARDs and tsDMARDs has allowed for an increasing proportion of patients to attain the treatment target. However, new bDMARDs and tsDMARDs primarily have access to the affluent markets because of their high price, thereby continuing to leave an unmet need in patients with RA in less affluent countries.⁶  

References:

1. Claxton L, Jenks M, Taylor M, et al. An economic evaluation of tofacitinib treatment in rheumatoid arthritis: modeling the cost of treatment strategies in the United Sates. J Managed Care Specialty Pharm. 2016;22(9):1088-1102.
2. American College of Rheumatology. Rheumatoid Arthritis. ACR website. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Rheumatoid-Arthritis. Updated March 2019. Accessed March 9, 2020.
3. McCormick N. Which patients with rheumatoid arthritis will start biologics, how soon, and why—much to learn from a universal coverage setting. JAMA Netw Open. 2019;2(12):e1917065. doi:10.1001/jamanetworkopen.2019.17065.
4. Tatangelo M, Tomlinson G, Paterson JM, et al. Association of Patient, Prescriber, and Region With the Initiation of First Prescription of Biologic Disease-Modifying Antirheumatic Drug Among Older Patients With Rheumatoid Arthritis and Identical Health Insurance Coverage. JAMA Netw Open. 2019;2(12):e1917053. doi:10.1001/jamanetworkopen.2019.17053
5. Magellan Rx Management. Medical Pharmacy Trend Report. 2019 Tenth Edition. Available at: https://www1.magellanrx.com/documents/2020/03/mrx-medical-pharmacy-trend-report-2019.pdf/. Published February 1, 2020. Accessed March 9, 2020.
6. Smolen JS , Landewé R , Breedveld FC , et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis 2010;69:964–75.doi:10.1136/ard.2009.126532
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