Long-term Persistence of First-line Biologics for Patients With Psoriasis and Psoriatic Arthritis in the French Health Insurance Database

Abstract

IMPORTANCETreatment options for psoriasis (PsO) and psoriatic arthritis (PsA) have evolved significantly throughout the era of biologics. Clinical trials are inadequate to assess the relative long-term efficacy of biologics and are often insufficient regarding safety.OBJECTIVES To assess the long-term persistence of different biologic classes to treat PsO and PsA. DESIGN, SETTING, AND PARTICIPANTSThis nationwide cohort study involved the administrative health care database of the French health insurance scheme linked to the hospital discharge database. All adults with PsO and PsA who were new users of biologics (not in the year before the index date) from January 1, 2015, to May 31, 2019, were included and followed up through December 31, 2019. Patients hospitalized for PsA in the PsO cohort and for PsO in the PsA cohort in the year before the index date were excluded. Data were analyzed from June 1 to October 31, 2021.MAIN OUTCOMES AND MEASURES Persistence was defined as the time from biologic therapy initiation to discontinuation and was estimated using the Kaplan-Meier method. Comparison of persistence by biologic class involved using propensity score-weighted Cox proportional hazards regression models and adjustment on specific systemic nonbiologics (time-dependent variables).RESULTS A total of 16 892 patients with PsO were included in the analysis (mean [SD] age, 48.5 [13.8] years; 9152 men [54.2%] men). Of these, 10 199 patients (60.4%) started therapy with a tumor necrosis factor (TNF) inhibitor; 3982 (23.6%), with an interleukin 12 and interleukin 23 (IL-12/23) inhibitor; and 2711 (16.0%), with an interleukin 17 (IL-17) inhibitor. An additional 6531 patients with PsA (mean [SD] age, 49.1 [12.8] years; 3565 [54.6%] women) were included; of these, 4974 (76.2%) started therapy with a TNF inhibitor; 803 (12.3%), with an IL-12/23 inhibitor; and 754 (11.5%), with an IL-17 inhibitor. Overall 3-year persistence rates were 40.9% and 36.2% for PsO and PsA, respectively. After inverse probability of treatment weighting and adjustment, the IL-17 inhibitor was associated with higher persistence compared with the TNF inhibitor for PsO (weighted hazard ratio [HR], 0.78 [95% CI, 0.73-0.83]) and PsA (weighted HR, 0.70 [95% CI, 0.58-0.85]) and compared with the IL-12/23 inhibitor for PsA (weighted HR, 0.69 [95% CI,). No difference between the IL-17 inhibitor and IL-12/23 inhibitor for PsO was noted. The IL-12/23 inhibitor was associated with higher persistence than the TNF inhibitor for PsO (weighted HR, 0.76 [95% CI, 0.72-0.80]), with no difference observed for PsA. CONCLUSIONS AND RELEVANCEThe findings of this cohort study suggest that IL-17 inhibitors are associated with higher treatment persistence than the TNF inhibitor for PsO and PsA. Interleukin 17 inhibitors were also associated with higher persistence than the IL-12/23 inhibitor for PsA, with no difference for PsO. However, the persistence rates of all biologics remained globally low at 3 years.

Persistence and Adherence to Biologics in Patients with Psoriasis in Taiwan: A New Biologics User Cohort Study

“…Given that the recommended maintenance dosing interval for ustekinumab is every 12 weeks (84 days), a 45-days gap may not be sufficient to assess discontinuation of ustekinumab. The study that used a 60-days treatment gap reported results that are consistent with our own; 1-year persistence in patients with psoriasis was 81.1% for ustekinumab versus 72.9% for adalimumab and 69.7% for etanercept ( Pina Vegas et al, 2022 ). Over the entire 3-years observation period ustekinumab was associated with higher persistence than all tumor necrosis factor inhibitors (HR 0.76, 95% CI 0.72–0.80) ( Pina Vegas et al, 2022 ).…”

“…The study that used a 60-days treatment gap reported results that are consistent with our own; 1-year persistence in patients with psoriasis was 81.1% for ustekinumab versus 72.9% for adalimumab and 69.7% for etanercept ( Pina Vegas et al, 2022 ). Over the entire 3-years observation period ustekinumab was associated with higher persistence than all tumor necrosis factor inhibitors (HR 0.76, 95% CI 0.72–0.80) ( Pina Vegas et al, 2022 ). Persistence was also substantially higher among ustekinumab users (70.8 versus 53.4% for adalimumab and 19.0% for etanercept) in the study that used a dose-defined treatment gap for each biologic ( Feldman et al, 2015 ).…”

“…We identified only 5 studies that previously reported persistence data for at least ustekinumab among new biologics users with psoriasis in which patients with psoriatic arthritis or other autoimmune diseases were excluded ( Howe et al, 2014 ; Feldman et al, 2015 ; Chastek et al, 2016 ; Sauer et al, 2016 ; Pina Vegas et al, 2022 ) ( Table 6 ). One study ( Howe et al, 2014 ) included only 7 patients who received ustekinumab and was not considered further.…”

“…We excluded patients who received biologics for reasons other than psoriasis, and although we have attempted to adjust for confounders, possible residual confounding, such as smoking status, alcohol intake ad other lifestyle and environmental factors exsits ( Zeng et al, 2017 ; Svanstrom et al, 2019 ; Zhou et al, 2020 ) could not be ruled out completely as this information is not recorded in the NHIRD. Other studies have reported a significant drop in persistence over time up until 3 years after treatment initiation ( Pina Vegas et al, 2022 ), suggesting that longer follow-up of patients may be needed to more fully understand treatment patterns using biologics. Finally, while the study is representative of biologics use for patients with psoriasis in Taiwan, it may be less applicable to other settings with different healthcare systems.…”

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)

“…This criterion can be considered a composite of efficacy (a treatment considered ineffective is likely to be discontinued) and safety (a poorly tolerated treatment is likely to be discontinued) but also of patient satisfaction or preference and adherence 14. Some studies have compared the persistence of biologics as first-line therapy in PsA,15–17 but although this is an important issue, limited data are available on persistence of second-line treatment in real life, particularly after TNFi discontinuation 18…”