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Comparative Treatment Patterns Among Psoriasis Patients Using Adalimumab, Etanercept, or Ustekinumab

This retrospective study compared the treatment patterns of ustekinumab with recommended maintenance administration every 12 weeks, with adalimumab and etanercept, administered weekly or every other week, for the treatment of plaque psoriasis.
Published Online: Oct 18,2016
Chureen Carter, PharmD, MS; Kathleen L. Wilson, MPH; David Smith, PhD; and Seina Lee, PharmD, MS
Objective: This retrospective study compared the treatment patterns of ustekinumab (UST), with recommended maintenance administration every 12 weeks, with adalimumab (ADA) and etanercept (ETA), administered weekly or every other week, for the treatment of plaque psoriasis.
Methods: Persons with psoriasis ≥18 years and having ≥1 medical or pharmacy claim for UST or ≥1 pharmacy claim for ADA or ETA, from February 8, 2010, to January 31, 2011, were selected from the MarketScan databases and assigned to mutually exclusive cohorts. Patient characteristics and dose escalation were described during the 12-month pre-index period and 12-month follow-up period, respectively. Differences in baseline characteristics were adjusted using inverse probability of treatment weights. Pairwise comparisons of rates of discontinuations, restarts, and switches were made between ADA and UST and between ETA and UST.
Results: A total of 2933 ADA, 4011 ETA, and 583 UST patients were selected. Patients in the UST cohort had higher baseline comorbidity scores and greater exposure to multiple psoriasis drugs at baseline. Dose escalation was observed in 7.8% of ADA patients, 30.9% of ETA patients, and 18.2% of UST patients. Discontinuations were seen in 38.6% of UST patients, 53.3% of ADA patients, and 56.2% of ETA patients. Restarts were seen in 8.9% of UST patients, 17.5% of ADA patients, and 23.1% of ETA patients. Switching to a nonindex medication occurred in 14.8% of UST patients compared with 22.0% of ETA patients and in 14.4% of UST patients compared with 20.8% of ADA patients.
Conclusions: Discontinuations, restarts, and switches were common for all 3 biologics, but were significantly lower among patients with psoriasis receiving UST compared with those receiving ADA or ETA.
Am J Pharm Benefits. 2016;8(5):191-198

Psoriasis is a chronic, immune-mediated, inflammatory skin disease affecting as many as 7.4 million Americans, or 3.2%of the United States population 20 years and older.1 Plaque psoriasis is the most common form and manifests as elevated red lesions covered by scaling silvery plaques. Psoriasis affects health-related quality of life, treatments can be costly and time-consuming, and patients with more severe psoriasis experience a greater negative impact on their quality of life.2-4

Three subcutaneously administered biologic drugs, adalimumab (ADA),5,6 etanercept (ETA),7,8 and ustekinumab (UST),9-12 are effective for use in the treatment of moderate to severe plaque psoriasis and improve health-related quality of life.13-15 ADA and ETA block the cytokine tumor necrosis factor-alpha (TNF-alpha) that is associated with inflammation.16

ADA is recommended for administration as an initial 80-mg dose (induction dose) followed by 40 mg every other week starting 1 week after the initial dose (maintenance period).7 ETA is recommended for administration as a 50-mg dose twice per week for 3 months (induction period) followed by a step down to a 50-mg dose once per week (maintenance period).5

UST, the most recently approved of the 3 biologics (approved September 25, 2009), selectively targets the cytokines interleukin 12 and 23 that are associated with psoriasis inflammation.10,17 UST is recommended to be administered at weeks 0 and 4, and then every 12 weeks thereafter. It is dosed by weight: 45 mg for patients ≤100 kg and 90 mg for patients >100 kg.9

All 3 products can be administered by healthcare professionals or self-administered by patients. Adjustments to the dosing and administration schedules of ADA and ETA are necessary for those responding suboptimally to the standard dosing regimen.18,19

Currently, few studies have been published comparing UST with the other subcutaneous biologic medications used to treat psoriasis in real-world clinical practice.20 The objectives of this study were to examine the dosing and timing of UST and to compare patient characteristics, dose escalation, discontinuation, restarts, and switching with the subcutaneous TNF-alpha inhibitors, ADA and ETA.