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A study of treatment patterns in people with psoriasis found lower persistence among those taking oral therapies, and sometimes-formidable costs associated with switching to new treatments.

The findings appeared recently in the .

This retrospective cohort study used commercial and Medicare claims data to evaluate patterns of switching, discontinuation, and nonswitching in psoriasis patients initiating oral (n=11,993) or biologic (n=9,753) systemic therapies. Among the oral and biologic cohorts, 32% and 15% discontinued index and any systemic treatment within 1 year of initiation. While 40% and 62% remained on index therapy, respectively, 28% and 23% ultimately switched treatments.

The decision to switch proved costly. In the oral therapy cohort, total per-patient per-month costs within 1 year of initiation was $2,594 for those who did not switch, $1,402 for patients who discontinued, and $3,956 for patients who switched. In the biologic cohort, the numbers were $5,035 for patients who did not switch; $3,112 for patients who discontinued; and $5,833 for patients who switched, respectively.

Report co-author Yichen Zhong is a lead immunology researcher for Bristol Myers Squibb, which sponsored the analysis. Zhong recently discussed the study and its findings with the Reading Room. The responses were edited for length and clarity.

Would you describe the impetus or "statement of need" for this investigation?

Zhong: Previous studies have reported high rates of switching and discontinuation among patients with psoriasis receiving systemic therapy. However, the economic consequence of switching and discontinuation remained unclear, especially the difference between patients initiating orals versus biologics.

Given the significant economic burden of psoriasis treatment on both patients and healthcare systems, understanding the economic consequences of different treatment strategies is crucial.

This study evaluated the costs associated with switching and discontinuation in patients initiated with oral versus biologic therapies.

What were the study's key findings?

Zhong: We assessed treatment patterns of U.S. psoriasis patients prescribed oral and biologic treatments in 2013-2019. (The four oral treatments prescribed were apremilast, cyclosporine, methotrexate, and acitretin; the biologics were etanercept, infliximab, ixekizumab, secukinumab, brodalumab, ustekinumab, guselkumab, adalimumab, certolizumab pegol, and tildrakizumab).

Patients who initiated treatment with biologics had higher overall costs than those who started with oral treatment. Within the first year, 28% of oral patients and 23% of biologic patients switched treatments. The costs were even higher when patients switched from oral to biologic or from one biologic to another, mainly due to the increased pharmacy costs.

A significant number of patients in the study who took oral therapy either discontinued the treatment or switched to biologics. What does this finding signal to you?

Zhong: Only 40% remained on their initial oral treatment after 1 year. Even worse, 32% became untreated. Although these findings suggest that the oral options available during the study period were not sufficient for many patients, the majority did not switch to biologics. This highlights the need for better oral medicines.

The investigation also found that patients who switched or discontinued biologics incurred a higher economic burden than patients who adhered to initial treatment.

Zhong: Anti-TNFs were the most used biologics during the study period, and their costs were relatively low compared to the more recently developed biologics. However, the persistence rates on anti-TNFs were low, and when these patients switched treatment, they were more likely to receive a more expensive biologic.

With the high pharmacy costs of biologics -- especially the more recent ones -- even in patients who adhered to the initial biologics, the costs were much higher than for patients initiated with oral treatment.

Any parting words?

Zhong: New, efficacious oral treatments with acceptable safety and tolerability could provide an option to alleviate disease burden, improve treatment persistence, and reduce the need for expensive branded biologics.