title: Treatment patterns following discontinuation of adalimumab, etanercept, and infliximab in a US managed care sample.
abstract: OBJECTIVE
  Because clinical guidelines do not offer clear recommendations for treatment options after discontinuing a tumor necrosis factor (TNF) blocker, this study evaluated treatment patterns within 360 days after discontinuation of TNF-blocker treatment.
  
  
  METHODS
  The IMS LifeLink Health Plan Claims database was used to identify patients diagnosed with rheumatoid arthritis, psoriasis, psoriatic arthritis, or ankylosing spondylitis who received etanercept, adalimumab, or infliximab between January 1, 2005 and March 31, 2009. Discontinuation from index (first) TNF blocker was defined as switching to a different TNF blocker or a >45-day gap in therapy. Patients were categorized into mutually exclusive groups in descending order: (a) restart of index TNF blocker; (b) switch to another TNF blocker; (c) switch to a different biologic; (d) switch to nonbiologic therapy; or (e) no new treatment.
  
  
  RESULTS
  Among 27,704 patients who initiated TNF-blocker therapy, 14,707 (53%) patients discontinued treatment over 1-3 years of follow-up. Within 360 days of discontinuing index TNF blocker, 53.4% of patients restarted index therapy: etanercept 59.9%, adalimumab 46.5%, and infliximab 43.1% (P < 0.001 for etanercept vs. adalimumab and infliximab). The majority of therapy restarts occurred within the first 3 months after discontinuation. Other patients switched to another TNF blocker: etanercept 17.1%, adalimumab 19.1% (P = 0.010 vs. etanercept), and infliximab 15.0% (P = 0.009 vs. etanercept). Switches from index TNF blocker to non-TNF-blocker biologic therapy were low: etanercept 1.9%, adalimumab 4.1%, and infliximab 10.7% (P < 0.001 for etanercept vs. adalimumab and infliximab). Switches from index TNF blocker to nonbiologic treatments were 5.4% for etanercept, 6.5% for adalimumab, and 6.9% for infliximab.
  
  
  CONCLUSIONS
  Restarting of index TNF-blocker therapy occurs frequently after discontinuation, suggesting that long gaps in TNF-blocker therapy may be common. A significantly higher proportion of etanercept patients restarted their index TNF blocker within 3 months of discontinuation, compared with adalimumab and infliximab patients.
authors.affiliation: Health Economics and Outcomes Research, IMS Health, 1725 Duke St., Suite 510, Alexandria, VA, 22314, USA, jyeaw@us.imshealth.com.
authors.forename: Jason
authors.initials: J
authors.lastname: Yeaw
authors.forename: Crystal
authors.initials: C
authors.lastname: Watson
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Fox
authors.forename: Vernon F
authors.initials: VF
authors.lastname: Schabert
authors.forename: Seth
authors.initials: S
authors.lastname: Goodman
authors.forename: Shravanthi R
authors.initials: SR
authors.lastname: Gandra
mesh_terms: D000068879:Adalimumab / Q000008:administration & dosage*; D000328:Adult; D018501:Antirheumatic Agents / Q000008:administration & dosage*; D015535:Arthritis, Psoriatic / Q000188:drug therapy; D001172:Arthritis, Rheumatoid / Q000188:drug therapy; D016208:Databases, Factual; D057915:Drug Substitution / Q000379:methods; D000068800:Etanercept / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D000069285:Infliximab / Q000008:administration & dosage*; D008297:Male; D008329:Managed Care Programs / Q000706:statistics & numerical data; D054539:Medication Therapy Management; D008875:Middle Aged; D012189:Retrospective Studies; D013167:Spondylitis, Ankylosing / Q000188:drug therapy; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*; D014481:United States; D028761:Withholding Treatment / Q000706:statistics & numerical data*
chemical_list: D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D000068879:Adalimumab; D000068800:Etanercept