title: Use of oral and subcutaneous methotrexate in rheumatoid arthritis patients in the United States.
abstract: OBJECTIVE
  To examine the patterns of methotrexate (MTX) use among rheumatoid arthritis (RA) patients.
  
  
  METHODS
  Using data from RA patients enrolled in a US commercial health plan and the US Medicare program, we identified RA patients initiating oral MTX. Persistence with MTX (oral or subcutaneous [SC]) was defined as no gap for ≥90 days.
  
  
  RESULTS
  New oral MTX users in Medicare (n = 20,431) were 76.9% women, had a mean ± SD age of 69.7 ± 11.7 years, and contributed a median followup of 2.6 years (interquartile range 1.7-3.5 years). Only 38% received dosages ≥20 mg/week at any time. Approximately 50% of patients discontinued MTX at 1 year, although more than one-third of patients subsequently restarted. New commercially insured oral MTX users (n = 4,048) were similar to Medicare patients, except for age. Among Medicare patients, 19% starting oral MTX subsequently initiated a biologic agent, mostly anti-tumor necrosis factor (85%). Of these, only 50% received MTX at a dosage of ≥20 mg/week, and only 21% of individuals switched to SC MTX (4%) or received hydroxychloroquine (8%), sulfasalazine (5%), or leflunomide (8%) prior to biologic agents. In commercially insured patients, 35% initiated a biologic agent, mostly anti-tumor necrosis factor therapies (90%). Of these, 43% never received MTX ≥20 mg/week.
  
  
  CONCLUSIONS
  Titration to a higher-dose oral MTX and use of SC MTX among RA patients were infrequent and may have been underutilized. Further work to optimize MTX dosing before patients are switched to a biologic agent may be warranted.
authors.affiliation: University of Alabama, Birmingham.
authors.forename: Jeffrey R
authors.initials: JR
authors.lastname: Curtis
authors.forename: Jie
authors.initials: J
authors.lastname: Zhang
authors.forename: Fenglong
authors.initials: F
authors.lastname: Xie
authors.forename: Tim
authors.initials: T
authors.lastname: Beukelman
authors.forename: Lang
authors.initials: L
authors.lastname: Chen
authors.forename: Joaquim
authors.initials: J
authors.lastname: Fernandes
authors.forename: Seth
authors.initials: S
authors.lastname: Ginsberg
authors.forename: Claire
authors.initials: C
authors.lastname: Spettell
authors.forename: Huifeng
authors.initials: H
authors.lastname: Yun
authors.forename: Kenneth G
authors.initials: KG
authors.lastname: Saag
authors.forename: Michael
authors.initials: M
authors.lastname: Schiff
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018501:Antirheumatic Agents / Q000008:administration & dosage* / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000453:epidemiology*; D001685:Biological Factors / Q000627:therapeutic use; D015331:Cohort Studies; D004305:Dose-Response Relationship, Drug; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007279:Injections, Subcutaneous; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D008727:Methotrexate / Q000008:administration & dosage* / Q000627:therapeutic use*; D008875:Middle Aged; D015999:Multivariate Analysis; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D018501:Antirheumatic Agents; D001685:Biological Factors; D008727:Methotrexate