The perplexity of prescribing and switching of biologic drugs in rheumatoid arthritis: a UK regional audit of practice

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.

Patient Perspectives on Intravenous Biologics for Rheumatologic Disease

“…For RA patients with active disease despite conventional DMARDs, current recommendations do not specify a treatment of choice from among approved anti–tumor necrosis factor (anti‐TNF) inhibitors (e.g., adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab) or the non‐TNF options (e.g., abatacept, anakinra, rituximab, sarilumab, tocilizumab, and tofacitinib) in some cases . The choice of biologic therapy for each patient is generally based on consideration of patient‐related factors, disease‐related factors, the mechanism of action of the prescribed medication, and patient preferences for treatment .

A general preference for subcutaneous biologic therapies has previously been reported among rheumatology patients. Results of the current surveys indicate that rheumatoid arthritis patients, including biologic‐naive patients, are generally open to intravenous or subcutaneous treatment. Patients receiving intravenous therapy express high satisfaction with this route of administration.

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Long-term follow-up of secondary amyloidosis patients treated with tumor necrosis factor inhibitor therapy

“…Moreover, switching between these agents is frequently necessary in inflammatory conditions due to adverse events and primary or secondary inefficacy. [ 27 ] Thus, information on the long-term efficacy and safety of these agents would help to develop management strategies in patients with secondary amyloidosis.…”

Real-Life Retention Rates and Reasons for Switching of Biological DMARDs in Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis

“…Biologic (b-) and targeted synthetic (ts-) disease-modifying anti-rheumatic drugs (DMARDs) represent a major therapeutic advance in rheumatology. However, response rates to b/tsDMARDs are variable ( 1 ); the evidence-base for directing switching from one agent to another is limited with most switches being empirical ( 2 , 3 ); and, responses to b/tsDMARDs regardless of the mechanism of action are generally similar ( 4 ). Furthermore, the overall rates of sustained remission and improvement in function are relatively modest ( 5 ), owing to several potential factors including lack of established criteria to direct initial or subsequent choice of one b/tsDMARD over another with a different MoA, following failure or inadequate response.…”