Economic and Formulary Considerations for Psoriatic Arthritis Treatment Options

Psoriatic arthritis (PsA) affects approximately 6% to 40% of patients with psoriasis and typically develops within 10 years of psoriasis onset. PsA and psoriasis are associated with comorbid conditions, such as cancer, cardiovascular disease, Crohn’s disease, depression, diabetes, obesity, osteoporosis, and liver disease, but treatment of PsA and psoriasis can alleviate comorbid condition symptoms or reduce the risk.

During a presentation at the Asembia 2020 Summit, Geoffrey C. Wall, PharmD, FCCP, BCPS, Ellis Distinguished Professor of Pharmacy Practice at Drake University College of Pharmacy and Health Sciences in Des Moines, IA, and Jamie L. McConaha, PharmD, NCTTP, BCACP, CDCES, associate professor of pharmacy practice at Duquesne University School of Pharmacy in Pittsburgh, PA, discussed treatment options for PsA.

Goals of PsA treatment include reduction of pain, improvements in other signs and symptoms, optimization of functional capacity and quality of life, and inhibition of progression of joint damage. The TICOPA study, published in The Lancet in 2015, found that American College of Rheumatology 20 response at 48 weeks was greater in a more tightly controlled/intensive management cohort (review every four weeks with escalation therapy) compared with standard care (review every 12 weeks).

Treatment options include non-pharmacologic therapies, symptomatic treatments (like corticosteroids), oral small molecules, tumor necrosis factor inhibitors, T-cell inhibitors, and interleukin (IL) and Janus kinase inhibitors.

Dr. McConaha discussed IL blockers ustekinumab, secukinumab, and ixekizumab. There is a risk of serious infections associated with IL blockers, so patients should be evaluated for tuberculosis infection prior to treatment. Use of these agents in patients with inflammatory bowel disease should be initiated with caution. Patients taking these medications cannot be given live vaccines and may exhibit diminished immune response to inactivated vaccines.

Next, Dr. Wall discussed formulary considerations for PsA treatments. PsA costs an estimated $135 billion per year (in 2013 U.S. dollars). The main drivers of cost include medical appointments and treatment, reduced productivity, comorbidities, reduced quality of life, and long-term treatment necessity. “Psoriasis as a whole is an expensive disease,” he said. “Reduced work productivity, treatment of comorbidities, reduced quality of life, and medical appointments actually play the big role in economic burden” of the disease, according to Dr. Wall, in addition to drug costs.

Actively screening patients across a variety of subspecialties can aid in early diagnosis and treatment of PsA. A Canadian study published in 2019 in Arthritis Care & Research found that use of the Psoriasis Epidemiology Screening Tool and other screening tools saved $2,000 per patient or potentially $220 million per year. He noted that community and specialty pharmacists can perform this screening.

Then, Dr. Wall discussed the cost-effectiveness of biologic options for PsA. The literature does not support one biologic that has the best cost-effectiveness profile. However, most biologics have incremental cost-effectiveness that would fall into willingness to pay thresholds per quality-adjusted life-year gained. Biosimilars will undoubtedly affect formulary selection and price in the coming years, he said. Specialty pharmacists can play a role in educating providers who may not be aware of biosimilars and monitoring patients who switch from a biologic to a biosimilar for adverse events (AEs) and loss of effect.

Dose reduction may be a possibility in patients with controlled psoriasis and PsA. Small reports suggest that this is feasible but there are concerns about drug antibody development and loss of effectiveness if the drug is needed again. This poses a potential to save money, and a current prospective pragmatic study is underway to assess this.

Dr. McConaha concluded the presentation by discussing the role of the specialty pharmacist to help ensure access to treatment by completing prior authorizations and appeals and ensuring affordability through assistance. Pharmacists can provide patient counseling on dosing frequency, route of administration, storage and disposal, time to expected response, adherence, AEs, and illness.

Pharmacists play a critical role in monitoring disease progression, educating patients about the disease and treatment, evaluating outcomes, and promoting appropriate patient monitoring. “It’s important to set realistic patient expectations as to when they can expect to have relief of their pain or feel better. We do not want them to not be adherent to medications or give up immediately if they think they are not working,” said Dr. McConaha. “In general, most patients start to see some response in a few weeks, roughly two to three weeks is fair to start to experience some relief of symptoms, but a lot of them can take months before they get their full clinical response.”

In the context of the current COVID-19 pandemic, the National Psoriasis Foundation provided recommendations for patients with psoriatic disease and does not recommend that all patients stop biologic therapy. Patients should stop if they have COVID-19 infection, and healthcare providers should consider the treatment being used, patient characteristics, and patient concerns, as patients on an oral immunosuppressive therapy and those older than 60 years who smoke and/or have chronic medical conditions are at a greater risk of infection.

Presentation: A Review of Psoriatic Arthritis Therapies for Specialty Pharmacists and Payers. Asembia 2020 Specialty Pharmacy Summit Virtual Experience, May 7, 2020.