Patterns of medication utilization and costs associated with the use of etanercept, adalimumab, and ustekinumab in the management of moderate-to-severe psoriasis.
BACKGROUND
Dose escalations of biologic agents may be attempted in the management of moderate-to-severe psoriasis. This has implications for the real-world cost of treatment.


OBJECTIVE
To examine the utilization patterns and costs associated with the use of etanercept, adalimumab, and ustekinumab among patients with moderate-to-severe psoriasis.


METHODS
This was a retrospective cross-sectional study. Patients with 2 or more medical claims with a diagnosis of psoriasis (excluding psoriatic arthritis) who were enrolled in large employer-sponsored health plans (including a pharmacy benefit) in the United States from January 2007 to March 2012 were identified and extracted from the MarketScan Commercial Encounters Database. Patients aged at least 18 years were required to have 2 or more pharmacy claims for etanercept, adalimumab, or ustekinumab; the index date was the first biologic fill date. Demographics and comorbidities were identified during the 1-year pre-index period, and medication utilization and costs were evaluated in the 1-year post-index period after a titration period according to the product prescribing information (2 weeks to 12 weeks). Medication utilization parameters such as dose escalation, dose reduction, persistence, switching, discontinuation, and restarts were assessed at 6, 9, and 12 months from the end of the dose titration window.


RESULTS
A total of 4,309 patients were included with a mean average age of 46 years, and 55% were male. Fifty-seven percent of the patients were started on etanercept, 39% on adalimumab, and 5% on ustekinumab. Patients had substantial dose escalation rates (etanercept: 41%; adalim-umab: 37%; ustekinumab: 36%, P  less than  0.05) and discontinuation rates (etanercept: 35%; adalimumab: 27%; ustekinumab: 16%, P  less than  0.05) over the 12-month post-titration period. Many patients also restarted the same biologic (etanercept: 37%; adalimumab: 10%; ustekinumab: 6%, P  less than  0.05) or switched to another biologic (etanercept: 15%; adalimumab: 10%; ustekinumab: 5%, P  less than  0.05) over the 12-month post-titration period. The persistence rates over 12 months were 19%, 53%, and 71% for etanercept, adalimumab, and ustekinumab, respectively (P  less than  0.05). Close to one-third of the patients at 6 months and 39% at 12 months postdose titration experienced a dose escalation. Approximately half of the patients who experienced a dose escalation also had a discontinuation or a dose reduction over the 12-month post-titration period.


CONCLUSIONS
Over one-third of psoriasis patients experienced a dose escalation of their biologic agents, and most of the dose escalation occurred during the first 6 months. Restarting, switching, and discontinuing index biologics were also common.
Novartis Pharmaceuticals, One Health Plaza, East Hanover, NJ 07936-1080. yang-3.zhao@novartis.com.
Steven R
SR
Feldman
Yang
Y
Zhao
Prakash
P
Navaratnam
Howard S
HS
Friedman
Jackie
J
Lu
Mary Helen
MH
Tran
D000068879:Adalimumab / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D000328:Adult; D018501:Antirheumatic Agents / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D004305:Dose-Response Relationship, Drug; D016527:Drug Costs; D000068800:Etanercept / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011565:Psoriasis / Q000188:drug therapy* / Q000191:economics / Q000503:physiopathology; D012189:Retrospective Studies; D012720:Severity of Illness Index; D014481:United States; D000069549:Ustekinumab / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*
D018501:Antirheumatic Agents; D000069549:Ustekinumab; D000068879:Adalimumab; D000068800:Etanercept