Treatment Pathways Leading to Biologic Therapies for Ulcerative Colitis and Crohn's Disease in the United States

Abstract

Objectives: Biologic therapies have been available for inflammatory bowel disease for >20 years, but patient outcomes have not changed appreciably over this time period. To better understand medication utilization for this disease, we evaluated a novel technique for visualizing treatment pathways, including initial treatment, switching, and combination therapies.

Methods: This retrospective, observational study used administrative claims data from the Truven Health MarketScan Commercial and Medicare Database. Adult patients with ≥2 consecutive health claims and newly diagnosed with ulcerative colitis (UC) or Crohn's disease (CD) were evaluated. Treatment pathways were visualized using Sankey diagrams representing the number of patients receiving treatment and duration of each treatment.

Results: In all, 28,119 patients with UC and 16,260 patients with CD were identified. The most common initial treatment for UC was 5-aminosalicylic acid monotherapy (61% of the patients), followed by corticosteroid monotherapy (25%); <1% of patients were initially treated with biologics. The most common initial treatment for CD was corticosteroid monotherapy (42%), followed by 5-aminosalicylic acid monotherapy (35%); <5% of the patients were initially treated with biologics. Significantly fewer patients followed biologic vs nonbiologic treatment pathways (UC: 6% vs 94%, CD: 19% vs 81%, both P < 0.05).

Discussion: Significantly fewer patients with inflammatory bowel disease followed treatment pathways that included biologic therapies compared with nonbiologic therapies, and very few patients were ever initiated on biologic therapy. Although we have made significant progress in treatment, our most effective medications are only being used in a small proportion of patients, suggesting barriers prevent optimized patient management.

Figure 1.

(a) Overall treatment pathways for UC depicted by Sankey diagrams. (b) First-line biologic treatment pathways for patients with UC. 5-ASA, 5-aminosalicylic acid; IMM, immunomodulator; Mono, monotherapy; other Combo Bio, other combination with a biologic; other Combo NonBio, other combination with a nonbiologic; UC, ulcerative colitis.

Figure 2.

(a) Overall CD treatment pathways depicted by a Sankey diagram. (b) First-line biologic treatment pathways for patients with CD. 5-ASA, 5-aminosalicylic acid; CD, Crohn's disease; IMM, immunomodulator; Mono, monotherapy; other Combo Bio, other combination with a biologic; other Combo NonBio, other combination with a nonbiologic.

Figure 3.

(a) Time to first biologic therapy for patients with CD, by first-line treatment. (b) Time to first biologic therapy for patients with UC, by first-line treatment. 5-ASA, 5-aminosalicylic acid; CD, Crohn's disease; CS, corticosteroid; IMM, immunomodulator; IST, immunosuppressive therapy ; Other Combo Nonbio, other combination with a nonbiologic; UC, ulcerative colitis UST, ustekinumab.

Figure 4.

Treatment pathways in UC incident cohorts for (a) 2008–2011 and (b) 2012–2014. 5-ASA, 5-aminosalicylic acid; IMM, immunomodulator; other Combo Bio, other combination with a biologic; other Combo NonBio, other combination with a nonbiologic; UC, ulcerative colitis.

Figure 5.

Treatment pathways in CD incident cohorts for (a) 2008–2011 and (b) 2012–2014. 5-ASA, 5-aminosalicylic acid; CD, Crohn's disease; IMM, immunomodulator; other Combo Bio, other combination with a biologic; other Combo Nonbio, other combination with a nonbiologic.