Underuse of Methotrexate in the Treatment of Rheumatoid Arthritis: A National Analysis of Prescribing Practices in the US

Abstract

Objective. Methotrexate (MTX) is the anchor drug in the treatment of rheumatoid arthritis (RA) due to its effectiveness, tolerability, and cost. This study examines MTX prescribing practices in the US from 2009 to 2014. Methods. Symphony Health Solutions, which covers 274 million patients in the US, was used to identify patients diagnosed with RA who were naive to MTX in 2009 and 2012. Data were collected, including medication use and doses, demographics, and medical comorbidities. Results. Of the patients who had 5-year followup data available, oral MTX was started in 35,640 in 2009, and 44% continued taking this dose during the followup. Of the 20,041 patients who changed therapy during the study period, 87% had the addition of or switched to a biologic agent, while 13% were changed from oral to subcutaneous (SC) MTX. The mean oral dose prior to the start of a biologic agent was 15.

Recommendations for optimizing methotrexate treatment for patients with rheumatoid arthritis

“…Analysis of RA-related claims from 2008 to 2010 indicated that only 1–15% of patients receiving nonbiologic monotherapy were switched to a biologic during 1 year of follow-up 19,20. This percentage is much smaller than that for patients who initiated treatment with MTX in 2009 or 2012 12,16. Results from a recent survey carried out in Italy, which included information from 1,336 RA patients, indicated that <40% had started treatment with MTX within 3–6 months from the diagnosis 21.…”

“…Since the introduction of TNF inhibitors in the late 1990s, there has been a gradual change in how MTX is used in clinical practice, with less aggressive dosing, shorter duration of use, and more rapid escalation to biologics 11–18. For patients starting treatment with a TNF inhibitor, concomitant use of MTX is also declining 12,16. The results of surveys and claims analyses have shown that MTX is administered orally in ~95% of patients and that the maximum dosage usually is 15 mg/wk 12,14.…”

Therapies for Active Rheumatoid Arthritis after Methotrexate Failure

“…In addition, in clinical practice, there is underutilization of subcutaneous methotrexate. Rohr et al looked at the use of subcutaneous methotrexate though national pharmacy registries [24]. It was shown that subcutaneous methotrexate is underutilized, and that physicians tend to add or switch to biologicals rather than switching the route of administration on a patient's methotrexate.…”

Personalized medicine in rheumatoid arthritis: methotrexate polyglutamylation revisited

“…The reasons/mechanisms for non-response have not been fully clarified but may include inter-individual differences in MTX uptake and/or metabolism, non-compliance or underdosing. In fact, a recent study indicated that in the United States, 63% of RA patients were under-dosed at MTX dosages <15 mg/wk [9] and thus treatment can be considered as ineffective.…”