Patient-reported reasons for the discontinuation of commonly used treatments for moderate to severe psoriasis
Patients with moderate to severe psoriasis have low long-term treatment persistence, but little is known about why they stop treatments. Discontinuation reasons for various treatments highlight the importance of treatment effectiveness, safety, convenience, cost, and other patientoriented factors in long-term treatment use.
A total of 1095 patients with moderate to severe plaque psoriasis from 10 dermatology practices was studied，patients stopped systemic treatments (MTX, Acitretin, Cyclosporine) and phototherapy (UVB and PUVA) after medians of 6 to 12 months and biologic agents (Etanercept, Adalimumab, Infliximab) after medians of 12 to 20.5 months. Side effects and lost efficacy are important limiting factors for treatment persistence.
Reasons for treatment discontinuation
Although most past treatments (70.8%) had only 1 discontinuation reason indicated, 22.6% had 2 reasons and 6.5% had 3 or more reasons. The frequency of citing each of 11 discontinuation reasons differed significantly by treatment (Table III). The most common reason for stopping etanercept was that it ‘‘worked well at first but stopped working well’’; for adalimumab was that it ‘‘did not work well enough’’; for infliximab, methotrexate, acitretin, and cyclosporine was non-life-threatening side effects; for UVB was treatment inconvenience and ‘‘psoriasis improved and prefer not to be on continuous treatment’’; and for oral PUVA was treatment inconvenience.
Of note, non-life-threatening side effects were often reported in patients stopping systemic therapies, infliximab and oral PUVA (21.0%-36.3%). This contrasts with life-threatening side effects, seen predominantly with infliximab (9.1%). Treatment inconvenience was noted by 22.3% to 31.5% of patients treated with UVB and oral PUVA phototherapy, as opposed to no more than 4% among those treated with systemic therapies and biologics. Denied insurance coverage was cited most often in stopping biologics and oral PUVA (4.7%-7.5%); post hoc analyses did not reveal significant difference in the proportions citing insurance denial among the 3 biologics (P = .55).
Four specific reasons were analyzed in fully adjusted regression models (Table IV). Despite indications that the random effects may not be normally distributed, the models have high discriminative abilities with area under the receiver operating characteristic curve ranging from 0.80 to 0.98. Compared with patients who received methotrexate, those who received adalimumab were more likely to cite that the treatment ‘‘did not work well enough,’’ whereas those who received etanercept, adalimumab, and infliximab were more likely to cite that the treatment ‘‘work welled at first but stopped working well.’’ Patients who received etanercept, adalimumab, and UVB phototherapy were less likely to stop treatment because of side effects than those who received methotrexate; in contrast, patients who received acitretin were more likely to stop treatment because of side effects. Patients who underwent UVB phototherapy were more likely to report an inability to afford treatment in its discontinuation than those who received methotrexate.
These results were largely robust to sensitivity analyses. After adjusting the models for all other reasons, point estimates of the associations between treatments and specific discontinuation reasons remained largely similar, except the odds ratios between acitretin and treatment ‘‘did not work well enough’’ and inability to afford treatment reached significance (data not shown). After excluding treatments that were received for less than 6 months, point estimates of the associations also remained similar.
