Abstract
IntroductionAfter a patient with rheumatoid arthritis (RA) fails tumor necrosis factor inhibitor (TNFi) treatment, clinical guidelines support either cycling to another TNFi or switching to a different mechanism of action (MOA), but payers often require TNFi cycling before they reimburse switching MOA. This study examined treatment persistence, cost, and cost per persistent patient among MOA switchers versus TNFi cyclers.MethodsThis study of Commercial and Medicare Advantage claims data from the Optum Research Database included patients with RA and at least one claim for a TNFi (adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab) between January 2012 and September 2015 who changed to another TNFi or a different MOA therapy (abatacept, tocilizumab, or tofacitinib) within 1 year. The index date was the date of the change in therapy. Treatment persistence was defined as no subsequent switch or 60-day gap in therapy for 1 year post-index. RA-related costs included plan-paid and patient-paid amounts for inpatient, outpatient, and pharmacy claims. Medication costs included index and post-index costs of TNFi and different MOA therapies.ResultsThere were 581 (38.3%) MOA switchers and 935 (61.7%) TNFi cyclers. The treatment persistence rate was significantly higher for MOA switchers versus TNFi cyclers (47.7% versus 40.2%, P = 0.004). Mean 1-year healthcare costs were significantly lower among MOA switchers versus TNFi cyclers for total RA-related costs ($37,804 versus $42,116; P < 0.001) and medication costs ($29,001 versus $34,917; P < 0.001). When costs were divided by treatment persistence, costs per persistent patient were lower among MOA switchers versus TNFi cyclers: $25,436 lower total RA-related cost and $25,999 lower medication costs.ConclusionMOA switching is associated with higher treatment persistence and lower healthcare costs than TNFi cycling. Reimbursement policies that require patients to cycle TNFi before switching MOA may result in suboptimal outcomes for both patients and payers.FundingSanofi and Regeneron Pharmaceuticals.
Highlights
After a patient with rheumatoid arthritis (RA) fails tumor necrosis factor inhibitor (TNFi) treatment, clinical guidelines support either cycling to another TNFi or switching to a different mechanism of action (MOA), but payers often require TNFi cycling before they reimburse switching MOA
Differences were observed between the cohorts for demographics and prior therapy, including the mean number of targeted disease-modifying antirheumatic drug (DMARD) received any time pre-index (1.07 for MOA switchers and 0.75 for TNFi cyclers; P\0.001) or the mean time from the first TNFi claim to the index date (727.6 versus 648.9 days, respectively; P = 0.078)
From the Kaplan–Meier analysis, median treatment persistence over the variable length follow-up after the change in therapy on the index date was 366 days for MOA switchers and 279 days for TNFi cyclers (Fig. 1)
Summary
After a patient with rheumatoid arthritis (RA) fails tumor necrosis factor inhibitor (TNFi) treatment, clinical guidelines support either cycling to another TNFi or switching to a different mechanism of action (MOA), but payers often require TNFi cycling before they reimburse switching MOA. This study examined treatment persistence, cost, and cost per persistent patient among MOA switchers versus TNFi cyclers. If disease activity remained moderate or high despite DMARD monotherapy, the recommendation was to switch to combination DMARD therapy or treatment with a tumor necrosis factor inhibitor (TNFi). If the initial TNFi was ineffective or poorly tolerated, patients could either switch to a different mechanism of action (MOA) or cycle to another TNFi. Recent updates to RA treatment guidelines recommend the use of different MOA therapies earlier in the treatment paradigm [5, 6]. Other MOA therapies are recommended either as an alternative option to a TNFi for first-line biological therapy [5] or as an option for second-line therapy after a TNFi instead of cycling to another TNFi [6]
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