Psoriasis : observational studies on clinical course, economic burden and treatment

Better understanding of long-term prognosis, clinical course, comorbidities, economic burden, and treatment of psoriasis, can improve care of patients with the disease and may inform decisions on resource allocation, benefitting not only patients but also the society in general. The Stockholm Psoriasis Cohort (SPC), Study 1, was initiated to describe the clinical course or psoriasis. The SPC enrolled 721 patients with onset of psoriasis within the last twelve months. 542 (75%) patients had plaque psoriasis and 174 (24%) had guttate psoriasis. Patients were followed in medical records and registers, and among the 686 participants alive after ten years, 546 (80%) responded to a questionnaire and 509 (74%) were also examined clinically. Plaque psoriasis was strikingly persistent. Forty one percent of the patients with severe disease at onset had severe disease at ten years compared with 9% of participants with mild or moderate disease at onset (Relative Risk [RR]=4.3; p<0.001). Guttate onset was associated with a favorable disease course: After ten years, 56/116 (48%) of patients were in remission without treatment and only 1/94 patients with mild or moderate guttate onset had severe psoriasis at ten years. Recursive partitioning analysis identified groups with distinctive risks for severe skin disease and Psoriatic Arthritis (PsA): The cumulative incidence of severe disease in participants with plaque phenotype, at least moderate disease, and scalp psoriasis at onset was 52% (95% Confidence Interval [CI]: 41% to 64%), compared to 11% (95% CI: 8% to 14%) in patients with mild disease at onset. Forty-eight of 82 patients (59%) with peripheral enthesitis at onset had PsA after ten years compared to 37/304 (12%) without arthralgia at onset (p<0.001). Systemic treatment at or before enrolment was associated with reduced risk for severe disease at ten years compared to systemic initiation later (Odds Ratio: 0.24; 95% CI: 0.06 to 0.90). Overall, this study indicates that the course of psoriasis can be predicted with good discriminatory power and that it may be modified by early effective intervention. The latter finding should be confirmed in randomized controlled clinical trials. The second study estimated all-cause and cause-specific mortality in 34,355 patients with mild psoriasis and 4,719 patients with severe psoriasis compared to 154,775 age- sex- and residency matched controls. The study found that patients with mild and severe psoriasis had excess all-cause mortality: Hazard ratio (HR) 1.15 (95% CI: 1.10 to 1.21) for patients with mild psoriasis, and HR 1.56 (95% CI: 1.36 to 1.79) for patients with severe psoriasis. Cardiovascular disease accounted for the largest proportion of excess mortality (48% in mild psoriasis and 33% in severe psoriasis). For patients with mild and severe psoriasis, the causes of death with the highest excess risks were kidney disease (HR: 2.20; 95% CI: 1.36 to 3.56), and liver disease (HR: 4.26; 95% CI: 1.87 to 9.73), respectively. The findings suggest that it may be valuable to screen patients with psoriasis for cardiovascular, kidney, and liver disease. Economic burden of psoriasis in 2010 and potential cost offsets with biologic treatment were estimated in Study 3, using data on 31,043 patients with psoriasis and 111,645 sex-, age- and residency-matched controls. Patients had higher direct and indirect costs compared to controls after adjusting for the Charlson Comorbidity Index (CCI): USD 3,555 versus USD 2,190 (p < 0.001) for direct costs and USD 9,898 versus USD 6,579 (p < 0.001) for indirect costs. Both mean direct and mean indirect costs generally increased with disease severity inferred by most potent treatment received, albeit the increase was not monotonic. Disregarding the costs of biologics, initiation of biologic treatment was estimated to generate one-year direct and indirect cost offsets from USD 1,135 (95% CI: 328 to 2,050) to USD 4,422 (95% CI: 2,771 to 6,552), and USD 774 (95% CI: -535 to 2,019) to USD 1,875 (95% CI: 188 to 3,650), respectively. Collectively, these findings show that psoriasis is associated with substantial direct and indirect costs, which may be modifiable with effective treatment. Study 4 described treatment patterns in 19,103 patients with psoriasis and estimated the oneyear cumulative incidences of treatment events (discontinuation, switch, or augmentation) with topicals, systemics, and biologics at 93%, 72%, and 75%, respectively. Within one year of having discontinued treatment, the cumulative incidences of starting a new treatment was 49% for topicals, 61% for systemics, and 80% for biologics. These findings highlight the unmet needs across the disease spectrum and underscore the chronicity of the disease. Study 5 estimated real-world effectiveness of adalimumab and etanercept compared to methotrexate. After adjusting for confounders, adalimumab had better drug survival (HR: 0.67; 95% CI: 0.51 to 0.88), lower mean predicted PASI (-2.0; 95% CI: -2.6 to -1.5) and DLQI (-0.9; 95% CI: -1.5 to -0.3) during maintenance treatment than methotrexate. The results for the comparison between etanercept and methotrexate were more mixed. These findings support adalimumab as first line systemic treatment for psoriasis, but further data, especially on safety and costs, are needed

Interleukin-17 and - 23 Inhibitors Associated with Direct Effects on Depressive Symptoms in Psoriasis: Results from a Register Study

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Health-related quality of life during the first year after a hip fracture: Results of the Mexican arm of the International Cost and Utility Related to Osteoporotic Fractures Study (MexICUROS)

Summary We investigated changes in health-related quality of life (HRQoL) due to hip fracture in Mexican adults aged ≥ 50 years during the first year post-fracture. Mean accumulated loss was 0.27 quality-adjusted life years (QALYs). HRQoL before fracture was the main contributor to explain the loss of QALYs. Introduction We aimed to estimate the health-related quality of life (HRQoL) loss over 1 year in patients sustaining a hip fracture in Mexico. Methods Individuals aged ≥ 50 years old with diagnosis of a low-energy-induced hip fracture enrolled in the International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS) composed the study population. After a recall of their own pre-fracture status, HRQoL was prospectively collected in three phases over 12 months of follow-up using EQ-5D-3L. The UK preference weight set was applied to calculate the utility values. The accumulated quality-adjusted life years (QALYs) loss in the first year post-fracture was estimated using the trapezoid method. Multivariate regression analysis allowed identifying determinants of QALYs loss. Results One hundred ninety-three patients (mean ± SD age 77.2 ± 9.9 years; 80% women; 15.5% with prior fracture in the last 5 years; 78% in low-income category) were evaluated. Mean (95% CI) utility value before fracture was 0.64 (0.59–0.68). It dropped to 0.01 (0.01–0.02) immediately after fracture and then improved to 0.46 (0.42–0.51) and 0.60 (0.55–0.64) at 4 and 12 months post-fracture, respectively. Disregarding fracture-related mortality, accumulated QALYs loss over the first year was 0.27 (0.24–0.30) QALYs. Mobility, self-care, and usual activities were the most affected domains throughout the whole year. HRQoL before fracture was the main contributor to explain the loss of QALYs. Conclusions Hip fractures reduce dramatically the HRQoL, with the loss sustained at least over the first year post-fracture in Mexico. The utility values derived from this study can be used in future economic evaluations

Increased Cause-specific Mortality in Patients with Mild and Severe Psoriasis: A Population-based Swedish Register Study

Several studies have shown excess risk for a number of comorbidities in patients with psoriasis compared with the general population, but data on cause-specific mortality in this patient population are limited. The aim of this study was to estimate the associations of psoriasis and 12 specific causes of death and all-cause mortality in patients with mild and severe psoriasis. The study was based on data from Swedish administrative registers and compared the risk of death in 39,074 patients with psoriasis with 154,775 sex-, age- and residency-matched referents using Cox proportional hazards models. In patients with mild and severe psoriasis, the strongest associations were observed for deaths due to kidney disease (hazard ratio [HR]=2.20, p<0.01) and liver disease (HR=4.26, p<0.001), respectively. Whilst cardiovascular disease was the main driver of excess mortality in absolute terms, the risks for other causes of death were also substantially elevated in patients with psoriasis compared with matched referents

Economic burden of psoriasis and potential cost offsets with biologic treatment : A swedish register analysis

Estimates of direct and indirect costs of psoriasis are limited. The aim of this study was to estimate: (i) costs in patients with psoriasis compared with controls; and (ii) impact on costs from initiating biologics. The study extracted data from Swedish administrative registers and compared 31,043 patients with 111,645 sex-, age- and residency-matched referents. Mean direct and indirect costs were estimated as US dollars (USD) 1,365 (62%) and USD 3,319 (50%) higher in patients compared with referents, respectively. The study included 352 patients treated with biologics who had at least 1-year follow-up before and after initiation of biologics. Among the 193 patients persistent with biologics for one year, 1-year costs of biologics were estimated at USD 23,293 (95% confidence interval (95% CI) 22,372−24,199). This cost was partially offset, with savings in direct costs estimated to range from USD –1,135 (95% CI –2,050 to –328) to USD –4,422 (95% CI –6,552 to –2,771), depending on assumptions. The corresponding estimates for indirect costs savings were from USD –774 (95% CI –2,019−535) to USD –1,875 (95% CI –3,650 to –188). The study suggests that psoriasis is associated with substantial costs, which may be modifiable with treatment

Health-Care and Societal Costs Associated with Non-Persistence with Subcutaneous TNF-α Inhibitors in the Treatment of Inflammatory Arthritis (IA) : A Retrospective Observational Study

Objective: A few studies have suggested that patients with inflammatory arthritis (IA) who remain persistent with subcutaneous TNF-α inhibitors (SC-TNFi) incur lower health care costs than patients who discontinue treatment, whereas data on the impact of non-persistence on indirect costs are largely lacking. Furthermore, existing estimates are based on fixed follow-ups, in relation to treatment initiation, and therefore do not measure costs in direct relation to treatment discontinuation. Therefore, by capturing costs in direct relation to treatment discontinuation, this study aimed to estimate direct and indirect costs associated with non-persistence with SC-TNFis in IA. Methods: Adult Swedish biologic-naïve IA patients initiating biologic treatment with a SC-TNFi (adalimumab, etanercept, certolizumab or golimumab) between May 6, 2010, and December 31, 2017, were identified in population-based registers with almost complete coverage. IA was defined as a diagnosis of rheumatic arthritis, ankylosing spondylitis/unspecified spondyloarthritis or psoriatic arthritis. Non-persistent patients were matched on propensity score to patients persistent with treatment by at least an additional 12 months. This enabled comparisons of direct healthcare costs and indirect costs for sick leave and disability pension, respectively, 12 months before and 12 months after treatment discontinuation. Results: A balanced cohort of 486 matched pairs was generated. The total direct and indirect costs were significantly higher among non-persistent patients already during the 12 months before index ($20,802 [18,335–23,429] vs.$16,600 [14,331–18,696]). However, while non-persistent patients increased their total direct and indirect costs, persistent patients significantly decreased the same, further widening the difference in costs during the 12-month period after index date ($22,161 [19,754–24,556] vs.$13,465 [11,415–15,729]). Conclusions: Among biologic-naïve Swedish IA patients treated with SC-TNFis, persistent patients incurred about 40% lower aggregated direct and indirect costs compared to non-persistent patients the year following SC-TNFi discontinuation. This highlights the impact of treatment persistence from an economic viewpoint, adding further aspects to the clinical perspective

True costs of patient management over 18 months following a hip, vertebral, distal radius, or proximal humerus fragility fracture in France - Results from the ICUROS Study

Annual Meeting of the American-Society-for-Bone-and Mineral Research, Orlando, FL, SEP 20-23, 2019International audienc

True costs of patient management over 18 months following a hip, vertebral, distal radius, or proximal humerus fragility fracture in France - Results from the ICUROS Study

Annual Meeting of the American-Society-for-Bone-and Mineral Research, Orlando, FL, SEP 20-23, 2019International audienc

True costs of patient management over 18 months following a hip, vertebral, distal radius, or proximal humerus fragility fracture in France - Results from the ICUROS Study

Annual Meeting of the American-Society-for-Bone-and Mineral Research, Orlando, FL, SEP 20-23, 2019International audienc