In a study that involved data from 274 million patients, researchers from the University of Nebraska Medical Center (UNMC) found that physicians are underutilizing methotrexate in the treatment of rheumatoid arthritis (RA). Led by James O’Dell, M.D., Bruce Professor of Internal Medicine and chief of the UNMC divisions of rheumatology and immunology, the team found that some physicians are also making the mistake of not keeping patients on the drug long enough before switching them to more expensive biologic drug options.
Doctors Underutilizing Methotrexate for RA
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Using the claims data, researchers followed the treatment of 35, 640 RA patients between 2009 and 2014. They found that 43.8% continued with oral methotrexate, 49.2% added or switched to a biologic treatment.
“If oral methotrexate is not producing the desired results, ” Dr. O’Dell said in the November 17, 2015 news release, “then 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% added a biologic instead of trying subcutaneous methotrexate, ” he said. “Patients switched to biologics too quickly—41% switched in three months or less.”
The study found that 72% of patients who switched from oral to subcutaneous methotrexate stayed on this treatment for five years. The other 28% eventually needed a biologic, at a median of 289 days on subcutaneous methotrexate.
Dr. O’Dell told OTW, “The work was originally done to look at the use of subcutaneous (SC) methotrexate (MTX)—we then expanded it because it was clear that MTX in general was badly underutilized. We were most surprised to learn the magnitude of underuse of MTX in terms of dosing, duration and route of administration.”
“Methotrexate is the best drug we have to treat rheumatoid arthritis. Unfortunately, clinicians in the U.S. are not using it early enough, are not using in at optimal doses and are rarely prescribing subcutaneous methotrexate (which is the most effective way to administer it). This results in under treatment of RA and overuse of biologicals.”
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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