Abstract
BackgroundBiologic drugs are expensive treatments used in rheumatoid arthritis (RA). Switching among them is common practice in patients who have had an inadequate response or intolerable adverse events. The National Institute of Health and Clinical Excellence (NICE) UK, which aims to curtail postcode prescribing, has provided guidance on the sequential prescription of these drugs. This study sought to evaluate the extent to which rheumatology centres across the Midlands were complying with NICE guidance on the switching of biologic drugs in RA, as well as analyse the various prescribing patterns of these drugs.MethodsData was collected via a web-based tool on RA patients who had undergone at least one switch of a biologic drug during 2011. The standards specified in NICE technology appraisals (TA130, TA186, TA195, TA198, and TA225) were used to assess compliance with NICE guidance. Descriptive statistical analysis was performed.ResultsThere were 335 biologic drug switches in 317 patients. The most common reason given for switching to a drug was NICE guidelines (242, 72.2%), followed by Physician's choice (122, 33.4%). Lack of effect was the most common reason for discontinuing a drug (224, 67%). For patients on Rituximab, Methotrexate was used in 133 switches (76.9% of the time). Overall NICE compliance for all units was 65% (range 50 to 100%), with anti-TNFα to anti-TNFα switches for inefficacy making up the majority of non-compliant switches.ConclusionThis study draws attention to the enigma and disparity of commissioning and prescribing of biologic drugs in RA. Currently the evidence would not support switching of a biologic drug for non-clinical purposes such as economic pressures. Flexibility in prescribing should be encouraged: biologic therapy should be individualised based on the mode of action and likely tolerability of these drugs. Further work should focus on the evidence for using particular sequences of biologic drugs.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2474-15-290) contains supplementary material, which is available to authorized users.
Highlights
Biologic drugs are expensive treatments used in rheumatoid arthritis (RA)
Our results demonstrate disparity in prescribing patterns between individual rheumatology centres, in terms of the number of switches and percentage of patients on a biologic drug being switched
There is a negative correlation between the number of patients on a biologic drug and the percentage of patients having six-monthly DAS-28 assessments in each rheumatology centre (Figure 5). In general, this audit, which represents over 95% of the population of the East and West Midlands, shows that most rheumatology centres are broadly compliant with National Institute of Health and Clinical Excellence (NICE) guidance on the switching of biologic drugs in their RA patients
Summary
Biologic drugs are expensive treatments used in rheumatoid arthritis (RA). Medications include traditional non-biologic and biologic disease-modifying antirheumatic drugs (tDMARDs and bDMARDs). Other classes of bDMARDs comprise B-Cell depleting therapy (Rituximab), Il-6 blocking therapy (Tocilizumab) and T-cell co-stimulatory inhibitor therapy (Abatacept) [7,8,9]. The efficacy of these agents has been validated in several randomised controlled trials and metaanalyses [10,11,12]. Switching (or cycling) among biologic therapies has been advocated where patients have shown an inadequate response or adverse events
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