Real-world trends in biologic, oral systemic, and phototherapy in US patients with psoriasis or psoriatic arthritis

Abstract

To the Editor: Biologics have transformed the treatment landscape for psoriasis and psoriatic arthritis (PsA) over the past 2 decades. Little is known about recent trends and predictors of biologic use in these disorders. We examined trends in real-world use of biologic, systemic, and phototherapies. We analyzed the 2001-2015 National Ambulatory Medical Care Survey, a cross-sectional, representative sample of US office-based physician visits. Psoriasis and PsA were identified by International Classification of Diseases, Ninth Revision, codes 696.1 and 696.0. Weighted frequencies/proportions of treatments were estimated, including systemic corticosteroids (SCSs), biologics, oral immunosuppressants, acitretin, and phototherapy. Treatment utilization trends were examined over 5-year intervals with logistic regression by using Stata, version 14.2 (StataCorp, College Station, TX). P values were corrected using the Benjamini-Hochberg approach. A weighted total (95% confidence interval) of 33,600,000 (29,400,000-37,800,000) psoriasis visits occurred from 2001 through 2015; 95.7% (94.3%-96.9%) were in adults, 49.6% (46.1-53.2%) in female patients, 78.4% (74.6%-1.7%) in white non-Hispanic patients, and 89.7% (85.6%-92.6%) in metropolitan areas. Systemic therapy was used in 20.9% (18.1%-24.0%) of visits, most commonly with biologics (8.0% [6.2%-10.3%]), followed by oral immunosuppressants (5.0% [3.8%-6.6%]), SCSs (3.5% [2.4%-5.2%]), and phototherapy (3.3% [2.2%-4.9%]). Visits with biologic use increased from 2001-2005 period to the 2011-2015 period (from 3.8% [1.5%-9.6%] to 13.1% [10.0%-16.9%] of visits; P = .01), particularly among dermatologists (from 4.1% [1.6%-10.3%] to 12.0% [9.0%-15.8%]; P < .001), privately insured patients (from 4.8% [1.6%-13.4%] to 17.3% [12.8%-23.0%]; P = .017), those residing in metropolitan areas (from 4.1% [1.6%-10.3%] to 12.0% [9.0%-15.8%]; P = .028), and those with PsA (from 19.1% [6.3%-45.4%] to 27.6% [15.9%-43.3%]; P = .01). Adalimumab (from 0.0% to 5.7% [3.8%-8.5%]) and ustekinumab (from 0.0% to 3.7% [2.0%-6.5%]) in particular increased over time. Oral retinoid use decreased over time (from 4.5% [1.9%-7.0%] to 1.7% [0.3%-3.0%]; P = .05); oral immunosuppressants (P ≥ .24) and phototherapy (P ≥ .06) did not. Psoriasis/PsA treatment has changed dramatically over the past 2 decades (Fig 1 and Supplemental Table I; available via Mendeley at https://data.mendeley.com/datasets/publish-confirmation/hsvnkcc8w8/2). Biologics were used at substantially higher rates (more than double) than oral systemic or phototherapy combined. Biologic use likely increased owing to better identification of moderate to severe disease, approval of multiple biologics, publication of long-term efficacy and safety data, improved payer coverage, patient-assistance programs, and direct-to-consumer advertising. Increasing biologic use over time was not offset by major decreases of other modalities, indicating that biologics expanded the moderate to severe psoriasis market and did not merely replace previous therapies. Surprisingly, SCS use persisted in metropolitan areas from 2001-2005 to 2011-2015 (from 1.7% [0-3.6%] to 5.6% [2.5%-8.7%], P = .15); 49.2% and 81.1% of SCS prescriptions for patients with psoriasis or PsA were in chronic follow-up visits. SCSs are not included in US or European psoriasis treatment guidelines, nor are they recommended for chronic management of PsA, owing to adverse events with long-term use, rebound flares, erythroderma, and generalized pustular psoriasis with short-term use.1Menter A. Korman N.J. Elmets C.A. et al.Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents.J Am Acad Dermatol. 2009; 61: 451-485Abstract Full Text Full Text PDF PubMed Scopus (446) Google Scholar Increasing use of SCSs over time and in the chronic management of psoriasis and PsA are important practice gaps warranting intervention. Study strengths include examination of a nationally representative cohort of outpatient visits for psoriasis. Limitations include lack of data on psoriasis severity and individual longitudinal treatment course. In summary, biologic use in psoriasis substantially increased over time in multiple patient subsets, whereas oral systemic and phototherapy use plateaued. SCS use remained prevalent over time, suggesting an important practice gap.