Patients under the care of the U.S. Veterans Affairs who were older, non-white and had more comorbidities were less frequently given biologic initiation therapy to treat their rheumatoid arthritis (RA), according to a recent study.
Researchers sought to identify predictors of greater use of biologic therapies, as well as factors associated with persistent use of glucocorticoids, in patients with RA. Results of the large cohort study, which reviewed a decade of data, were published in The Journal of Rheumatology.1
“What stands out is that there are big differences in how [physicians] treat older and sicker versus younger and healthier patients,” says study author Michael George, MD, MSCE, a rheumatologist and instructor of medicine at Penn Medicine, a division of the University of Pennsylvania, Philadelphia.
The use of biologics raises questions of the possibilities of both undertreatment and overtreatment of patients with RA, note the authors. Those scenarios can change depending on access and treatment patterns.
Some patients whose disease could be controlled with conventional disease-modifying anti-rheumatic drugs may wind up being overtreated, while those who continue strictly with conventional treatments despite active disease could be undertreated, which can lead to chronic use of glucocorticoids, according to the authors.
“The goal would be to get people on the therapy they need right off the bat, as opposed to a trial-and-error [approach to] find the exact therapy someone needs,” explains Dr. George.
“For now, we don’t have a good way of predicting who is going to need which treatment and that’s why there is often a step-up approach, starting with methotrexate and then adding other medicines to it, like a biologic,” he says. “If that doesn’t work, we try a different one.”
Researchers gleaned clinical and administrative information from three U.S. Veterans Affairs databases spanning from 2005–16 to identify patients with RA who were receiving a first-ever prescription of methotrexate. To identify an inception cohort, the study required patients to have six months or more of baseline data within the VA system before the first methotrexate prescription.
Study criteria were designed to include a homogenous group of patients with RA that was severe enough to be prescribed methotrexate. Selecting a population with newly initiated methotrexate therapy enabled researchers to study patients at a similar phase of their disease who were first treated with methotrexate, considered the backbone of treatment for RA.
“People define early [biologic] use differently,” says Dr. George, explaining the study did not include patients who began biologics first, before any other type of therapy. “We were taking the more common situation of people who are starting methotrexate. … They are probably relatively early on in their disease.
“Then we look out two years to ask, ‘Who are the people who are going to go on to start a biologic within that time frame?’”
Of 39,789 patients who had a diagnosis of RA and a first prescription of methotrexate, there were 17,415 who met all inclusion criteria. Among the patients included in the study, 45% were 65 years or older, 88% were men, and 73% were white, according to the article.