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Association between depression, anxiety, chronic pain, or opioid use and tumor necrosis factor inhibitor persistence in inflammatory arthritis

Abstract

Introduction

Depression, anxiety, and chronic pain are common comorbidities in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) and may substantially impact patient outcomes. We aimed to determine whether these comorbidities were associated with earlier TNF-inhibitor (TNFi) discontinuation.

Methods

This retrospective cohort study using Optum’s de-identified Clinformatics® Data Mart Database 2000–2014 identified patients with RA, PsA, and AS initiating a first TNFi. Depression/anxiety, chronic pain, and opioid use were identified using diagnosis codes and prescription fill data. Cox proportional hazards models were used to compare time to medication discontinuation in patients with or without each of these risk factors and to assess the additive effect of having multiple risk factors.

Results

Among 33,744 patients initiating a TNFi (23,888 RA, 6443 PsA, 3413 AS), depression/anxiety, chronic pain, and opioid use were common, with ≥ 1 risk factor in 48.1%, 42.5%, and 55.4% of patients with RA, PsA, and AS respectively. Each risk factor individually was associated with a 5–7-month lower median treatment persistence in each disease (all p < 0.001). Presence of multiple risk factors had an additive effect on time to discontinuation with HR (95% CI) 1.19 (1.14–1.24), 1.41 (1.33–1.49), and 1.47 (1.43–1.73) for 1, 2, or 3 risk factors respectively in RA. Findings were similar in PsA and AS.

Conclusions

Depression, anxiety, chronic pain, and opioid use are common in inflammatory arthritis and associated with earlier TNFi discontinuation. Recognizing and managing these risk factors may improve treatment persistence, patient outcomes, and cost of care.

Key Points
• Depression, anxiety, chronic pain, and opioid use are common in patients with inflammatory arthritis.
• In patients initiating treatment with a TNF-inhibitor, depression, anxiety, chronic pain, or recent opioid use are associated with sooner discontinuation of TNFi therapy.
• Patients with multiple of these risk factors are even more likely to discontinue therapy sooner.

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Data availability

Optum data is governed by a data use agreement and is available to license through Optum.

Code availability

Available upon request.

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Authors and Affiliations

Authors

Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Guy Katz and Michael D. George. The first draft of the manuscript was written by Guy Katz and Michael D. George, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Guy Katz.

Ethics declarations

Ethics approval

As this study utilized a de-identified dataset, the study was deemed exempt by the University of Pennsylvania Institutional Review Board.

Ethical standards statement

The manuscript does not contain clinical studies or patient data.

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Not applicable.

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Not applicable.

Conflict of interest

Dr. Guy Katz has no disclosures. Dr. Alexis Ogdie has served as a consultant for AbbVie, Amgen, BMS, Celgene, Corrona, Gilead, Global Health Living Foundation, Janssen, Lilly, Novartis, Pfizer, and UCB (less than 10,000 each in past 12 months) and has received grants from Novartis and Pfizer to Penn and from Amgen to Forward (grants more than 10,000). Dr. Joshua Baker has received consulting fees from Bristol-Myers Squibb and Gilead. Dr. Michael George is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases 1K23AR073931-01.

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Katz, G., Ogdie, A., Baker, J.F. et al. Association between depression, anxiety, chronic pain, or opioid use and tumor necrosis factor inhibitor persistence in inflammatory arthritis. Clin Rheumatol 41, 1323–1331 (2022). https://doi.org/10.1007/s10067-021-06045-3

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  • DOI: https://doi.org/10.1007/s10067-021-06045-3

Keywords

  • Depression
  • Pain
  • Rheumatoid arthritis
  • Spondyloarthritis
  • Treatment