Cost a Secondary Factor in Biologic Choices by Pediatric Rheumatologists

Anink J, Otten MH, Gorter SL, et al., Treatment choices of paediatric rheumatologists for juvenile idiopathic arthritis: etanercept or adalimumab? Rheumatology (2013) 52:1674-1679
doi:10.1093/rheumatology/ket170 [epub ahead of print]

In daily clinical practice, pediatric rheumatologists choose the TNF-α inhibitor etanercept over adalimumab for most of their patients with juvenile idiopathic arthritis (JIA) largely because they have more experience with and find more evidence in favor of the drug. Considerations of cost-effectiveness take a back seat to these clinical matters.
 
Analysis of focus group interviews with rheumatologists who had treated 214 biologic-nave active JIA patients, selected from the Dutch Arthritis and Biologicals in Children (ABC) register, cites the main reasons for the less-common choice of the newer option, adalimumab, as patient history of uveitis, longer disease duration, and lower disease activity.

The study involved two separate interviews with 20 participating rheumatologist. Most respondents felt that when two drugs are equally effective, the emphasis should be on patient-centered factors, with cost considerations a secondary factor.

All told, 90% of methotrexate-refractive patients (median age 12) were started on etanercept (n=193) and the rest (n=21) given adalimumab between March 2008 (when adalimumab became available) and December 2011.
 
The main reasons for choosing etanercept over adalimumab:

1)    Allowing young patients to avoiding the pain that accompanies adalimumab injection
2)    Longer availability of etanercept formulation for pediatric use
3)    Recent pediatric version of adalimumab still contains adult dose
4)    Greater personal experience with etanercept
5)    A longer track record of published data about safety and effectiveness for etanercept (10 years, versus 4 years for adalimumab)

Physicians were most likely to choose adalimumab in the presence of a history of uveitis and of patient complaints that suggested inflammatory bowel disorder (IBD) when lacking any objective confirmation of that disease. Enthetis-related arthritis and juvenile psoriatic arthritis were also mentioned as potential reasons.