A Comparison of Rheumatoid Arthritis Related Medical Visits by Patients Being Treated

with Tumor Necrosis Factor Alpha Antagonist Monotherapy and in Combination with
Methotrexate
Terkoski EM, Bitting AC, Pannier AD, VRx Pharmacy Services, LLC, P.O. Box 9780, Salt Lake
City, UT 84109; eterkoski@student.roseman.edu 813.625.4466
BACKGROUND: Rheumatoid Arthritis (RA) places a significant economic burden on the US
Healthcare System, which totals $39.2 billion annually. RA guidelines recommend that after the
failure of a DMARD combination that an aTNF be added or used exclusively. Data has shown
that there is a >90% probability that aTNF+MTX combination therapy results in significantly
improved pain control compared to aTNF monotherapy. While aTNF agents cost $32,000 each
year per patient, it is imperative that individuals receive optimal therapy that is aligned with the
evidence. This retrospective study will describe observed differences between RA patients being
treated with aTNF monotherapy versus aTNF+MTX combination therapy.
METHODS/DESCRIPTION: Administrative pharmacy and medical claims data from a
commercial health plan were analyzed to identify patients using aTNF agents with a diagnosis of
RA in 2013. Patients were stratified into combination and monotherapy groupsthose who
filled MTX and an aTNF product two or more times within the same time period were included
in the aTNF+MTX combination group, and all other patients were stratified into the aTNF
monotherapy group.
The medical claims data contrasted between the two groups included the percentage of patients
that required RA related office visits, the total number of RA related office visits, and the total
cost of the office visits. A Z-test with a significance level of 0.05 was used to compare office
visit occurrence related to RA between each group.
RESULTS: A total of 141 patients were included for analysis (aTNF monotherapy [n=99] and
aTNF+MTX [n=42]). Patients using aTNF monotherapy were 12 times more likely to visit their
doctor (59.6% vs. 4.8%, respectively [p < 0.05]) and had more frequent visits (mean of 3.41
visits/patient/year vs. 0.62 visits/patient/year, respectively) compared to the aTNF+MTX
combination therapy group. This correlated to a 550% increase in the number of visits per patient
per year.
As expected, the increased frequency of visits experienced in the monotherapy group led to more
money being spent for medical visits linked to RA each year. On average patients using aTNF
monotherapy spent more than 5 times the amount than patients using combination therapy
(mean of $32,679.33/patient/year vs $5,681.06/patient/year).
CONCLUSIONS: Combination therapy with an aTNF+MTX resulted in a reduced number of
office visits compared to aTNF monotherapy. Although clinical outcomes were not specifically
measured, the observed reduction in office visits may be representative of superior disease
control with the aTNF+MTX combination.
Additional analyses evaluating the financial implications of these observations demonstrated that
patients receiving aTNF+MTX combination therapy spent significantly less money each year on
medical visits. Knowing this, it is surprising that only 30% of the patients identified were

receiving optimal disease management. As healthcare costs continue to increase it is paramount

that actions be taken to ensure the use of evidence based medicine, particularly with expensive
medications driving up the cost of healthcare.