Significant variations in global access to biologic DMARDs for spondyloarthritis
medwireNews: The prescription of biologic (b)DMARDs for spondyloarthritis (SpA) patients varies significantly across countries, according to the findings of the ASAS-COMOSPA study.
Looking at 3370 patients from 22 countries across four continents, the study found that crude mean bDMARD use was the lowest in China, at 5%, and the highest in Belgium, at 74%. Significant variations in bDMARD use by country remained after full adjustment for sociodemographic and clinical variables.
“The findings suggest unequal and unjust selection of treatment for SpA independent of clinical indication, an observation that necessitates urgent attention on the health equality and public health agenda,” write Elena Nikiphorou (King’s College London, UK) and colleagues in the Annals of the Rheumatic Diseases.
The use of bDMARDs in SpA has been extensively studied and there is robust evidence for their efficacy in reducing disease activity and improving function, mobility, and quality of life. In contrast, say the researchers, the existing evidence consistently shows a lack of efficacy for conventional synthetic (cs)DMARDs in axial SpA, with international guidelines not supporting their use in patients with only axial disease. In the current study, across all countries, 1275 (38%) patients were bDMARD users, while 1168 (35%) used csDMARDs.
In multivariable analysis, higher bDMARD uptake was associated with greater country health expenditure, although this failed to reach statistical significance. The odds of using bDMARDs doubled with the past use of bDMARDs or csDMARDs, and other variables significantly associated with bDMARD uptake included male sex (odds ratio (OR)=1.26), the presence of axial (versus peripheral) disease (OR=1.62), sacroiliitis on X-ray (OR=1.41), and the presence of extra-articular disease manifestations (OR=1.31).
These associations were reversed when looking at csDMARD uptake, which also showed a significant variation across countries. Commenting on the association of lower country welfare with higher csDMARD use, the researchers note that: “Given the lack of evidence for efficacy of csDMARDs in [axial] SpA and the available evidence consistently showing no efficacy, this reflects an unjust selection of treatment for patients in countries of lower socioeconomic welfare, based on decisions other than clinical indication.”
The researchers speculate that although most national recommendations follow international guidelines for SpA management, there could be “hidden” barriers across individual countries limiting access to bDMARDs, including differences in the funding of healthcare provision, variations in local or regional budgets, and difficulties in accessing more expensive drugs.
By Catherine Booth
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