Study Shows Low Persistence Rate for Biologics in Previously TNF-Exposed Patients with Psoriatic Arthritis

A real-life study reported low persistence for all biologics at the 3-year mark in patients with psoriatic arthritis (PsA) who were previously exposed to a tumor necrosis factor inhibitor (TNF), according to a study published in RMD Open.¹ Results indicated that persistence was higher in patients receiving an interleukin-17 (IL-17) or IL-12/23 when compared with TNF.

Laura Pina-Vegas, MD

“Tumor necrosis factor inhibitor (TNF) agents are most often the first-choice biological treatment for patients with PsA,” lead investigator, Laura Pina-Vegas, MD, of the rheumatology department at the Hôpital Henri Mondor in Creteil, France, stated. “When their discontinuation is needed, a switch to another TNFi or to another therapeutic class may be considered. However, data supporting one approach over another are lacking.”

Adult patients with PsA starting a second-line biological after discontinuing a TNF were enrolled in the nationwide cohort study. Data from the French health insurance system (Système National des Données de Santé [SNDS]), which was linked to the hospital discharge database, were utilized during the study period spanning from January 2015 through December 2020. Data included sociodemographic data, reimbursements for health-related expenditure, outpatient medical care, nursing care, pharmacy-dispensed medications, medical interventions, and information related to admissions to French hospitals.

The primary outcome was persistence of a biologic, both originator and biosimilar. Persistence, defined as the time from biologic initiation to discontinuation (a period of over 60 days without refilling the same prescription), was assessed by the Kaplan-Meier method.

Poisson regression models, divided into 6-month intervals, were used to compare the persistence by biological class. Investigators emphasized the importance of treatment persistence for determining the value of a drug as well as an indicator of patient interest.

In total, 2975 patients started a second-line biologic during the study period, with 53% (n = 1580) initiating a second TNF, 33% (n = 969) starting an IL-17, and 14% (n = 426) initiating an IL-12/23. The mean age was 47 years, 35% were male, and the median follow-up was 229 days. During the follow-up period, 73% (n = 2168) patients discontinued their second-line biologic. At 1-year, 2-year, and 3-year marks, persistence rates were 42%, 25%, and 17%, respectively.

Persistence was linked to treatment with IL-17 or IL-12/23 (adjusted relative risk [RRa] 0.79, 95% confidence interval [CI] 0.71 to 0.87 and RRa 0.69, 95% CI 0.61 to 0.79, respectively) when compared with TNF. There were no significant differences between patients receiving IL-17 and IL-12/23 (RRa 0.88, 95% CI 0.76 to 1.02).

Hospital prescriber information was incomplete. However, sensitivity analysis after excluding these patients reported stable results. Further, while investigators defined drug exposure based on reimbursement data, which may not be equivalent to days of use, adherence rates are typically higher for biologics when compared with other treatment categories. Investigators mitigated potential channeling bias by limiting the analyses to patients receiving a second therapeutic biological sequence after discontinuing a first TNF. Lastly, information collected in the database did not specify why a patient discontinued a biologic.

Despite this, the cohort included a large sample of patients from a national database, which ensures homogenous data processing, thus limiting selection bias.

“This real-life study… highlights that long-term control of PsA most often requires multiple therapeutic lines, including molecules with different modes of action,” Pina-Vegas concluded. “Further studies, including head-to-head randomised trials, would be useful to confirm these findings and identify patient subgroups that may benefit from one management strategy over another.”

References

1. ^{Pina Vegas L, Hoisnard L, Bastard L, Sbidian E, Claudepierre P. Long-term persistence of second-line biologics in psoriatic arthritis patients with prior TNF inhibitor exposure: a nationwide cohort study from the French health insurance database (SNDS). RMD Open. 2022;8(2):e002681. doi:10.1136/rmdopen-2022-002681}