title: The perplexity of prescribing and switching of biologic drugs in rheumatoid arthritis: a UK regional audit of practice.
abstract: BACKGROUND
  Biologic 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.
  
  
  METHODS
  Data 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.
  
  
  RESULTS
  There 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.
  
  
  CONCLUSIONS
  This 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.
authors.affiliation: Rheumatology Department, Haywood Hospital, High Lane, Burslem, Staffordshire ST6 7AG, UK. timblakewarwick@gmail.com.
authors.forename: Tim
authors.initials: T
authors.lastname: Blake
authors.forename: Vijay
authors.initials: V
authors.lastname: Rao
authors.forename: Tahir
authors.initials: T
authors.lastname: Hashmi
authors.forename: Nicola
authors.initials: N
authors.lastname: Erb
authors.forename: Sheila Catherine
authors.initials: SC
authors.lastname: O'Reilly
authors.forename: Shireen
authors.initials: S
authors.lastname: Shaffu
authors.forename: Karen
authors.initials: K
authors.lastname: Obrenovic
authors.forename: Jon
authors.initials: J
authors.lastname: Packham
mesh_terms: D000368:Aged; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000453:epidemiology*; D001688:Biological Products / Q000191:economics / Q000627:therapeutic use*; D003625:Data Collection / Q000379:methods; D057915:Drug Substitution / Q000191:economics / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008485:Medical Audit / Q000191:economics / Q000592:standards*; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000592:standards*; D006113:United Kingdom / Q000453:epidemiology
chemical_list: D001688:Biological Products