Rheumatologists’ bDMARDs prescribing the target of government-funded program

Specialists’ prescribing of bDMARDs is being put under the spotlight by a new NPS MedicineWise-led program that aims to get the “best health and economic outcomes” for use of the expensive drugs.

Rheumatologists and clinical immunologists are the first target of the Value in Prescribing bDMARDs Program which will see them sent reports on their prescribing, with some to receive targeted educational visits.

Gastroenterologists prescribing of bDMARDS for Crohn’s disease and ulcerative colitis, and dermatologists prescribing for psoriasis will also be targeted in follow-up programs early next year.

The program is run by the Targeted Therapies Alliance (TTA): funded by a Federal government grant, it is a consortium of nine organisations led by NPS MedicineWise and including Arthritis Australia, the Australian and New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network and the Australian Rheumatology Association among others.

“These biological medicines are part of the fastest-growing sector of the pharmaceutical market. This is an increasingly complex area for consumers, specialists and pharmacists to navigate,” the NPS says.

The program comes after two bDMARDs, adalimumab and ustekinumab, were listed among the top 10 most costly PBS/RPBS drugs to the Government in 2018/19.

Individualised prescribing data

NPS MedicineWise and the Australian Rheumatology Association this month sent reports to 450 rheumatologists and immunologists, giving individualised data on their prescribing of bDMARDS and other rheumatology drugs, together with comparisons to average prescribers.

The PBS Practice Review reports were “intended for health professional personal reflection and not regulatory auditing processes,” the NPS said. “The report encourages optimisation of first line treatment and aims to help guide treatment decisions around choice of biologics and minimisation of glucocorticoid and opioid use.”

Some specialists will be targeted with invitations for an ‘educational visiting service’ (otherwise known as academic detailing), involving tailored education about prescribing of the bDMARDs.

The TTA will also develop new evidence-based “living guidelines” on aspects of prescribing, as well as new resources and tools for patients, pharmacists, nurses, hospitals and Drug and Therapeutics Committees.

Dr Jonathan Dartnell, Manager, Programs and Clinical Services at NPS, said the evidence was “moving quickly” on bDMARDS and the program had a number of aims, including ensuring people were diagnosed within a shorter period of time and that first-line therapies were used optimally.

“If they are used optimally, it may be that they don’t need to proceed to a bDMARD,” he said.

One of the first areas of focus was providing clinicians with clear guidance on down-titrating the dosage of bDMARDS, he said, with draft recommendations for dose reduction and discontinuation of b/tsDMARDs released for public comment.

Dr Dartnell said bDMARDS were an area of high expenditure and the program aimed to ensure efficiency in their use, but “not at the expense of health outcomes”.

OPAL database excluded

Chair of OPAL (Optimising Patient Outcomes in Australian RheumatoLogy), Professor Geoffrey Littlejohn, said that after an initial discussion, OPAL was not invited to be part of the TTA consortium, despite having a database of prescribing information covering 110 rheumatologists and 50,000 RA patients.

While the OPAL database couldn’t provide information on whether doctors were mis-prescribing rheumatology drugs, he said “we do know that when people get into remission, most doctors try to reduce any drug to the lowest dosage”.

“Most doctors are not prescribing drugs for the sake of it,” he said.

However, Professor Littlejohn, Emeritus Director of Monash Health Rheumatology, said a major issue with bDMARD prescribing was that some PBS restrictions around the drugs dated back to clinical practice 18 years ago when the first biologics became available, and were now out-of-date.

For example, patients were required to have 20 active (swollen and tender) joints (or four active major joints) in order to qualify for bDMARDs on the PBS – which dated from a time when patients generally started treatment when they had very active RA.

However, clinical trials for newer drugs were generally based on treating patients who had six swollen and eight tender joints, he said.

“There is a disconnect between the current restrictions and the way clinical practice runs now – we want to get people under control as quickly as possible,“ Professor Littlejohn said.

“It is time to relook at the PBS rules.”

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