Rheumatologist suggests number one arthritis drug is underutilized, underdosed

James O'Dell, M.D., Bruce Professor of Internal Medicine and chief of the UNMC divisions of rheumatology and immunology, delivered the message at the annual meeting of the American College of Rheumatology and the Association of Rheumatology Health Professionals in San Francisco.

"There are some major concerns here," Dr. O'Dell said. "It shows that we're not doing all we should with methotrexate, our number one therapy for rheumatoid arthritis."

Methotrexate is the anchor drug for a class of drugs known as disease-modifying anti-rheumatic drugs (DMARDs). The DMARDS are much less expensive than the other class of drugs used to treat RA called biologics. Previous studies have shown that the DMARDs produce the same clinical benefits in the majority of RA patients as the biological treatment.

To better understand how methotrexate is utilized for RA treatment in the United States, Dr. O'Dell's research team performed an exhaustive review of anonymous claims data on 274 million patients, representing 92 percent of all prescription drugs written in the U.S. The claims data was produced by Symphony Health Solutions.

From this data, researchers were able to follow the treatment course of 35,640 RA patients between 2009 and 2014. The key findings were: • 15,599 (43.8 percent) continued treatment with oral methotrexate. • 17,528 (49.2 percent) added or switched to a biologic treatment. • A biologic was added at a median of 170 days and 41.5 percent of patients added a biologic agent within 90 days of the initiation of oral methotrexate. • Only about 7 percent of patients followed were switched from oral to subcutaneous administration of methotrexate.

If oral methotrexate is not producing the desired results, Dr. O'Dell said the next step should be to try patients on subcutaneous methotrexate at a higher dose.

"What we found in patients who made a treatment change was that 87 percent added a biologic instead of trying subcutaneous methotrexate," he said. "Patients switched to biologics too quickly -- 41 percent switched in three months or less."

Dr. O'Dell said switching to subcutaneous methotrexate can prevent the need for -- or significantly extend the time to -- a biologic.

The study found that 72 percent of patients who switched from oral to subcutaneous methotrexate stayed on this treatment for 5 years. The other 28 percent eventually needed a biologic, at a median of 289 days on subcutaneous methotrexate.

"The bottom line," Dr. O'Dell said, "is that more appropriate optimization of methotrexate could lead to better control of RA and produce significant cost savings. Oral methotrexate is underdosed in clinical practice, and subcutaneous methotrexate is underutilized."

Dr. O'Dell hopes to submit his research findings to a leading scientific journal in the near future.