Drugs for rheumatoid arthritis provided by the Unified Health System in 2019 in Brazil: a cohort study

Oliveira, Ana Liani Beisl; Lima, Elisangela Costa; Campos, Mônica; Luiza, Vera Lucia

doi:10.1590/1413-81232023285.13482022

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FREE THEMES • Ciênc. saúde coletiva 28 (05) • May 2023 • https://doi.org/10.1590/1413-81232023285.13482022EN linkcopy

Drugs for rheumatoid arthritis provided by the Unified Health System in 2019 in Brazil: a cohort study

Authorship SCIMAGO INSTITUTIONS RANKINGS

This study analyzes supply characteristics and factors associated with the treatment of rheumatoid arthritis in Brazil, with a focus on disease course-modifying biological drugs (bioDMARDs). A retrospective study was conducted with secondary data from the Outpatient Information System of the Unified Health System. Patients aged 16 years or older who were treated in 2019 were eligible. The analyses were performed with exposure factors in relation to the outcomes: bioDMARD use and population size. The study included 155,679 patients, 84.6% of whom were women. There was a greater exchange of bioDMARDs and a greater supply of rheumatologists in the larger municipalities (more than 500,000 inhabitants). Almost 40% of the patients used bioDMARDs, and they showed greater adherence to treatment (57.0% versus 64%, p=0.001). The dispensing of bioDMARDs occurred in more than one-third of the patients treated for rheumatoid arthritis (RA) in Brazil and was associated with a higher percentage of availability of rheumatologists and larger population size.

Key words:
Rheumatoid Arthritis; Biological drugs; Pharmaceutical Services

Variables		Municipality size (in number of inhabitants)			p-value &	Total
Variables		up to 100,000	100,000 to 500,000	+500,000
Number of patients with RA		15,112	51,123	89,444	-	155,679
Demographic and clinical characteristics of users
	Women	83.3%	83.4%	85.4%	0.000	84.6%
	Weight (kg) (mean; 95%CI)	72.0 (71.78-72.22)	71.9 (71.81-72.05)	71.0 (70.94-71.12)	0.000	71.4 (71.36-71.49)
	Height (cm) (mean; 95%CI)	161.7 (161.60-161.88)	161.5 (161.45-161.61)	160.8 (160.72-160.83)	0.000	161.1 (160.07-161.16)
	Body mass index (BMI) (average; 95%CI)	27.46 (27.37-27.54)	27.43 (27.38-27.47)	27.35 (27.32-27.39)	0.006	27.39 (27.36-27.41)
	Age (years) (mean; 95%CI)	57.0 (56.80-57.21)	57.1 (56.97-57.20)	56.9 (56.78-56.96)	0.012	56.9 (56.89-58.02)
Provision of medication for RA
Main diagnosis (ICD-10)*
	M05.0	5.6%	10.9%	10.2%	-	10.0%
	M05.1	0.2%	0.3%	0.3%	-	0.3%
	M05.2	0.2%	0.2%	0.2%	-	0.2%
	M05.3	3.1%	4.8%	5.3%	-	4.9%
	M05.8	53.3%	46.1%	55.8%	-	52.4%
	M06.0	29.1%	26.7%	21.3%	-	23.8%
	M06.8	8.5%	10.8%	6.9%	-	8.4%
Type of APAC**
	Continuity	65%	59.0%	65.6%	0.000	63.4%
	Initial	34.5%	41.0%	34.4%	0.000	36.6%
Number of dispensations per patient/year
	Patient dropouts ^#1	3.3%	2.9%	3.1%	0.031	3.0%
	Patient adherence ^#2	57.7%	63.5%	57.6%	0.000	59.6%
Period of treatment (months)		9.87	10.00	9.72	0.000	9.83
Number of dispensations per month (mean; 95%CI)		0.94 (0.93-0.95)	0.96 (0.96-0.97)	0.95 (0.94-0.95)	0.000	0.95 (0.95-0.95)
Switch to a biological drug		2.8%	2.8%	3.9%	0.000	3.4%
Change in medication for arthritis		11.0%	10.2%	14.1%	0.000	12.5%
Number of dispensations per year (mean; 95%CI)		8.52 (8.46-8.58)	8.89 (8.86-8.92)	8.36 (8.33-8.38)	0.000	8.55 (8.5-8.6)
Provision of RA care and municipality characterization
Number of rheumatologists per 1,000 patients with RA (mean; 95%CI)		1.19 (1.14-1.25)	4.01 (3.96 - 4.05)	9.48 (9.45-9.51)	0.000	6.9 (6.85-6.91)

Variables		Dispensing of bioDMARDs		p-value &	Total
Variables		No	Yes
Number of patients with RA		98,475	57,204	-	155,679
Demographic characteristics of users
	Women	64.0%	36.0%	0.000	100%
	Mens	59.1%	40.9%	0.000	100%
	Weight (kg) (mean; 95%CI)	71.1 (71.05-71.22)	71.9 (71.81-72.04)	0.000	71.4 (71.36-71.49)
	Heigt (cm) (mean; 95%CI)	160.8 (160.79-160.90)	161.6 (161.52-161.66)	0.000	161.1 (161.07-161.16)
	Body mass index (BMI) (mean; 95%CI)	27.4 (27.33-27.39)	27.4 (27.40-27.48)	0.345	27.4 (27.36-27.41)
	Age (years) (mean; 95%CI)	57.6 (57.56-57.72)	55.8 (55.66-55.88)	0.000	57.0 (56.89-57.02)
Provision of medication for RA
Main diagnosis (ICD-10)*
	M05.0	60.1%	39.9%	-	100%
	M05.1	94.8%	5.2%	-	100%
	M05.2	95.9%	4.1%	-	100%
	M05.3	61.2%	38.8%	-	100%
	M05.8	62.1%	37.9%	-	100%
	M06.0	66.6%	33.4%	-	100%
	M06.8	64.1%	35.9%	-	100%
Type of APAC**
	Continuity	64.6%	61.3%	0.000	63.4%
	Initial	35.4%	38.7%	0.000	36.6%
Number of dispensations per patient/year
	Patient dropouts ^#1	3.3%	2.6%	0.000	3.0%
	Patient adherence ^#2	57.0%	63.9%	0.000	59.6%
Period of treatment (months)		8.0	8.0	0.000	8.0
Number of dispensations per month (mean; 95%CI)		0.94 (0.94-0.95)	0.97 (0.96-0.97)	0.000	0.95 (0.95-0.95)
Number of dispensations per year (mean; 95%CI)		8.35 (8.33-8.37)	8.89 (8.86-8.92)	0.000	8.55 (8.53-8.57)
Provision of RA care and municipality characterization
Number of rheumatologists per 1,000 patients with RA (mean; 95%CI)		6.53 (6.5-6.57)	7.48 (7.43-7.52)	0.000	6.9 (6.85-6.91)

Medicines	ICD-10 codes* main diagnosis %							All ICD-10	Sex %		Population size %
Medicines	M05.0	M05.1	M05.2	M05.3	M05.8	M06.0	M06.8		F	M	Up to 100.000	100.000-500.000	More than 500.000
Patients N (%)	15,507 (10.0)	427 (0.3)	365 (0.2)	7,674 (4.9)	81,534 (52.4)	37,118 (23.8)	13,054 (8.4)	155,679 (100.0)	131,643 (84.6)	24,036 (15.4)	15,112 (9.7)	51,123 (32.8)	89,444 (57.5)
Synthetic disease-modifying drugs- csDMARDs (% column)
Leflunomide (20 mg)	35.3%	1.6%	1.6%	34.9%	36.8%	33.4%	32.7%	25.2%	35.6%	32.9%	33.1%	34.8%	35.8%
Hydroxychloroquine (400 mg)	14.1%	3.3%	0.5%	9.9%	10.2%	17.5%	14.8%	10.0%	13.1%	9.9%	22.3%	13.7%	10.4%
Methotrexate (2.5 mg and 25 mg/mL)	8.4%	0.5%	1.1%	14.6%	12.6%	12.2%	13.2%	8.9%	12.2%	12.0%	15.3%	11.4%	12.1%
Sualfasalazine (500 mg)	1.9%	0.2%	0.5%	1.5%	2.3%	3.2%	3.1%	1.8%	2.4%	3.2%	4.0%	2.2%	2.4%
Chloroquine (150 mg)	0.2%	0.0%	0.0%	0.1%	0.2%	0.3%	0.2%	0.1%	0.2%	0.2%	0.2%	0.2%	0.2%
Subtotal	60.0%	5.6%	3.8%	61.0%	62.0%	66.5%	64.0%	46.1%	63.5%	58.2%	75.0%	62.3%	60.8%
Immunosuppressants (% column)
Azathioprine (50 mg)	0.1%	82.7%	78.9%	0.2%	0.1%	0.1%	0.0%	23.1%	0.4%	0.7%	0.3%	0.5%	0.5%
Cyclosporine (20, 25 and 100 mg)	0.0%	6.6%	13.2%	0.0%	0.0%	0.0%	0.0%	2.8%	0.1%	0.1%	0.0%	0.0%	0.1%
Subtotal	0.1%	89.2%	92.1%	0.2%	0.1%	0.1%	0.0%	26.0%	0.5%	0.8%	0.4%	0.5%	0.6%
Nonsteroidal anti-inflammatory drugs - NSAIDs (% column)
Naproxen (250 and 500 mg)	0.1%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.1%	0.0%	0.0%	0.0%
Subtotal	0.1%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.1%	0.0%	0.0%	0.0%
Biological course-of-disease-modifying drugs - bioDMARDs (% column)
Adalinumab (40 mg)	16.3%	0.9%	0.8%	14.3%	11.7%	11.8%	11.6%	9.6%	11.7%	15.4%	8.5%	12.5%	12.7%
Etanercept (25 and 50 mg)	8.4%	0.2%	0.0%	8.2%	7.7%	6.8%	7.6%	5.6%	7.2%	9.4%	5.6%	7.3%	8.0%
Golimumab (50 mg)	4.0%	0.0%	0.3%	3.4%	3.1%	2.8%	2.8%	2.3%	3.0%	3.3%	2.1%	3.2%	3.2%
Tocilizumab (20 mg/mL)	2.7%	0.5%	0.3%	2.3%	3.2%	2.1%	3.4%	2.1%	2.9%	2.2%	1.4%	2.7%	3.1%
Certolizumab Pegol (200 mg)	2.5%	0.0%	0.3%	2.6%	3.1%	3.0%	2.0%	1.9%	2.9%	2.6%	2.5%	2.9%	2.9%
Infliximab (10 mg/mL)	2.3%	0.5%	0.5%	1.9%	2.3%	2.2%	2.5%	1.8%	2.1%	3.4%	1.3%	2.9%	2.1%
Abatacept (250 mg and 125 mg/mL)	1.6%	0.7%	0.0%	2.6%	3.0%	1.6%	2.5%	1.7%	2.5%	1.9%	1.3%	2.5%	2.6%
Rituximab (10 mg/mL)	1.0%	1.2%	1.6%	1.8%	1.8%	1.3%	1.7%	1.5%	1.6%	1.2%	0.5%	1.3%	1.9%
Tofacitinib (5 mg)	1.2%	1.2%	0.3%	1.8%	2.1%	1.8%	1.9%	1.5%	2.0%	1.5%	1.4%	1.6%	2.1%
Subtotal	39.9%	5.2%	4.1%	38.8%	37.9%	33.4%	35.9%	27.9%	36.0%	40.9%	24.6%	37.1%	38.6%
Total	100%	100%	100%	100%	100%	100%	100%	100%	100%	100%	100%	100%	100%

Variables		OR-bruto	CI	p- value	OR-aj	CI	p- value
Demographic characteristics of users
	Men	1.232	(1.198-1.267)	0.000	1.190	(1.151-1.230)	0.000
	Weight (kg)*	1.004	(1.004-1.005)	0.000	1.002	(1.002-1.003)	0.000
	Height (cm)*	1.010	(1.009-1.012)	0.000	1.003	(1.002-1.005)	0.000
	Age (years)*	0.989	(0.988-0.990)	0.000	0.988	(0.987-0.989)	0.000
Provision of medication for Rheumatoid Arthritis
	Type of APAC Continuity	1.152	(1.128-1.177)	0.000	1.073	(1.046-1.100)	0.000
	Number of dispensations per patient/year*	1.042	(1.039-1.045)	0.000	1.017	(1.009-1.025)	0.000
	Period of treatment (months)*	1.035	(1.031-1.038)	0.000	1.021	(1.014-1.028)	0.000
	Patient dropouts ^#1 (Yes)	1.333	(1.305-1.362)	0.000	1.156	(1.107-1.208)	0.000
	Patient adherence ^#2 (Yes)	0.778	(0.731-0.828)	0.000	0.904	(0.837-0.976)	0.012
	Number of dispensations per month (mean; 95%CI)*	1.075	(1.057-1.093)	0.000	1.052	(1.020-1.084)	0.001
	Change in medication for arthritis (Yes)	1.260	(1.224-1.302)	0.000	1.133	(1.097-1.170)	0.000
Provision of RA care and municipality characterization
	Number of rheumatologists per 1,000 patients with RA*	1.033	(1.031-1.035)	0.000	1.037	(1.035-1.039)	0.000

location_on

ABRASCO - Associação Brasileira de Saúde Coletiva Av. Brasil, 4036 - sala 700 Manguinhos, 21040-361 Rio de Janeiro RJ - Brazil, Tel.: +55 21 3882-9153 / 3882-9151 - Rio de Janeiro - RJ - Brazil
E-mail: cienciasaudecoletiva@fiocruz.br

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[TFN9] ICD-10 codes (The International Classification of Diseases)*: M05.0 Felty syndrome; M05.1 Rheumatoid lung disease; M05.2 Rheumatoid vasculitis; M05.3 Rheumatoid arthritis with involvement of other organs and systems; M05.8 Other seropositive rheumatoid arthritis; M06.0 Seronegative rheumatoid arthritis; and M06.8 Other specified rheumatoid arthritis, Type of APAC**: Authorization for High Complexity/Cost Procedures. ^#1 Patient dropouts: patients who sought csDMARDs and/or bioDMARDs in only 20% of the total number of possible dispensations. ^#2 Patient adherence to treatment (patients with at least 80% of the maximum possible dispensations, both for csDMARDs and for bioDMARDs). & p-valor da ANOVA to the continuous variables and Pearson’s chi-square test to categorical variables.

[TFN10] Source: Authors.