Elderly Psoriasis Patients Show Poor Adherence to Biologics

Medicare patients treated for psoriasis have low biologic adherence and high discontinuation rates, according to a new study that found slightly more than one-third of the patients were adherent to their index biologic and almost half discontinued within 12 months of initiation of therapy.

"The most important finding of this study was that only 38% of Medicare patients who newly started a biologic for psoriasis continued on treatment for at least one year,” says senior author Joel Gelfand, M.D., a professor of dermatology at the University of Pennsylvania. “Given that psoriasis requires chronic treatment, this study demonstrates that there remains an unmet medical need for treatments that can successfully control psoriasis over the long term in the broader population of patients in the U.S.."

Psoriasis can have significant physical and psychosocial impact on patients, and the burden appears to increase along with the severity of the disease, which may lead to treatment noncompliance. Patient perception of psoriasis, choice of medication and personal factors are some of the causes for non-adherence to therapy. Psychosocial factors are consistently associated with adherence, according to a recent systematic review of factors associated with nonadherence to treatment for immune-mediated inflammatory diseases, including psoriasis. The authors suggest that clinicians may need to address treatment beliefs, provide practical advice on taking treatment and improve communication with patients to provide more effective care. [[{"type":"media","view_mode":"media_crop","fid":"51154","attributes":{"alt":"©AlexanderRaths/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_4712245639906","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6297","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"©AlexanderRaths/Shutterstock.com","typeof":"foaf:Image"}}]]

In the new study, Dr. Gelfand and colleagues examined national claims data for Medicare patients with psoriasis who were initiating biologics to investigate adherence, discontinuation, switching, and restarting of biologic treatment. Previous U.S.-based studies of biologic utilization patterns for psoriasis have focused on privately insured patients. The researchers state this is the first study to explore this issue among the elderly and disabled who are covered under Medicare. “Lack of data on the treatment of psoriasis in the elderly has been identified as a major research gap, especially because they are often underrepresented in clinical trials and may have unique treatment concerns,” they state.

They conducted a retrospective claims analysis using 2009 through 2012 100% Medicare Chronic Condition Data Warehouse Part A, B, and D files, with 12-month follow-up after index prescription. Specifically, they examined 2,707 moderate-to-severe plaque psoriasis patients in the cohort who initiated treatment during 2010-2011 with the biologics infliximab, etanercept, adalimumab or ustekinumab.

The researchers found that the patients’ use of biologics during the year following initiation, on average, translated into medication coverage for only 61% of the days in that year. Those patients whose prescriptions covered at least 80% of the days were classified as “adherent” to their medication; only 38% of patients reached this threshold.

Nearly half of the patients (46%) discontinued their medication during the year. Relatively few patients (8%) switched to another biologic, and 9% restarted biologic therapy after a gap of at least 90 days.

“Given that prior research has shown interruptions in biologic treatment for psoriasis to be associated with poorer outcomes compared to continuous therapy, understanding the reasons for treatment non-adherence is critical,” says Gelfand.

Several factors might have affected adherence, and the researchers identified higher out-of-pocket costs as a strong possibility. Patients who were ineligible for subsidies under Medicare Part D were more likely to be non-adherent and discontinue their biologic treatment. Female patients also were more likely to be non-adherent.

“Suboptimal patterns of biologic use warrant further investigation, however, our findings do suggest that high out-of-pocket costs under Medicare Part D are a potential factor,” says lead author Jalpa A. Doshi, M.D., of Penn Medicine.

The analysis found differences in adherence depending on which biologic agent the patients were taking. Those on etanercept were less likely to be adherent and those using self-administered biologics (etanercept and adalimumab) were more likely to discontinue as compared with those on ustekinumab. The researchers note that ustekinumab was administered under the supervision of a physician during the study. “This may partly reflect greater awareness of adherence problems (that is, missed appointments indicate missed doses) and thus greater opportunity for intervention when patients are receiving treatment in the office,” they state.

“Regardless, low adherence and high discontinuation rates were observed for all four of the biologics,” Dr. Doshi said.

The researchers note that as compared to younger, privately insured psoriasis patients, “Medicare beneficiaries are more likely to have had psoriasis for a longer period of time and/or be disabled, to have more comorbidities and competing health priorities, and to have different drug cost-sharing arrangements.”

They plan to further explore both patient- and provider-reported reasons for patterns in biologic treatment use, as well as explore the long-term health care costs associated with interruptions, discontinuations, and switches in moderate to severe plaque psoriasis biologic treatments.

References:

Katrina Hutton Carlsen , Adel Olasz, et al. Chapter, “Psoriasis and Adherence to Therapy: Individual, Treatment-Related and General Factors,”Adherence in Dermatology. pp 101-119. Date: 11 May 2016

Eleni Vangeli, Savita Bakhshi, et al. “A Systematic Review of Factors Associated with Non-Adherence to Treatment for Immune-Mediated Inflammatory Diseases,” Advances in Therapy. First Online: 07 November 2015; DOI: 10.1007/s12325-015-0256-7

Jalpa A. Doshi, Junko Takeshita, et al.  “Biologic therapy adherence, discontinuation, switching, and restarting among patients with psoriasis in the US Medicare population,”Journal of the American Academy of Dermatology. June 2016. DOI: http://dx.doi.org/10.1016/j.jaad.2016.01.048