SAN FRANCISCO – Oral methotrexate is frequently underdosed, given for an inadequate length of time, and rarely switched to subcutaneous formulations before rheumatologists move on to biologics, according to an analysis of claims data from 35,640 rheumatoid arthritis patients.
Dr. James O'Dell
“There’re some major concerns here. Methotrexate is the anchor drug for rheumatoid arthritis, the best drug we have. More appropriate [use] could lead to better control” and “produce significant cost savings,” said investigator Dr. James O’Dell, chief of the division of rheumatology at the University of Nebraska Medical Center, Omaha.
When patients don’t fully respond to lower doses, the ground rules for oral methotrexate include escalation up to 25 mg or a switch to subcutaneous formulations, which have better bioavailability. Those moves should be considered before turning to biologics, Dr. O’Dell explained at the American College of Rheumatology annual meeting.
Rheumatologists, by and large, aren’t playing by those rules, according to the analysis. “We need to own these data because the majority of patients, over three-quarters, were treated by rheumatologists. We are not doing a great job,” Dr. ODell said.
The claims data came from Symphony Health Solutions, which captures about 92% of prescriptions written in the United States. The 35,640 rheumatoid arthritis patients in the study were started on methotrexate in 2009 and followed through 2014; 15,599 (43.8%) didn’t need anything else and stayed on oral methotrexate alone throughout the study period.
Prescribers, however, gave up on oral methotrexate at a mean dose of 15.3 mg and moved 17,528 patients (49%) straight to a biologic without giving subcutaneous methotrexate a shot. They did that after a median of less than 6 months, and within 3 months in more than 40% of patients.
Just 2,513 patients (7%) moved on to subcutaneous methotrexate when their oral formulation wasn’t enough. That’s all most of them needed; 1,802 (72%) remained on subcutaneous methotrexate alone for the remainder of the study period. The rest moved on to a biologic, but after a median of almost a year, not a few months. When their time on oral and subcutaneous methotrexate was included, their median time to a biologic was more than 2 years.
The investigators checked to see if things improved for patients who started on oral methotrexate in 2012. “The answer was no. We didn’t do better,” Dr. O’Dell said.
He didn’t speculate on why methotrexate is underused in the United States.
Claims data can’t address why patients were switched from methotrexate and other issues, but such nuances “don’t even begin to explain the doses and the timing of switch that we saw here,” he said.
Dr. O’Dell is an adviser for AbbVie, Lilly, Coherus, Bristol-Myers Squibb, Antares, and Medac. Other investigators disclosed relationships with those or other companies.