Poor Outcomes in SLE Potentially Modifiable by Eliminating Cost Concerns

Eliminating unaffordable medication costs for treatment of systemic lupus erythematosus (SLE) could potentially attenuate risk factors for poor outcomes, according to results of a cohort study published in The Journal of Rheumatology.

Racial and ethnic groups most affected by SLE may be disproportionately subject to drug-cost concerns. Investigators evaluated the association between patient-reported medication cost concerns and patient-reported outcomes (PROs) among a multiethnic cohort of individuals with SLE.

The California Lupus Epidemiology Study (CLUES) included patients from the San Francisco Bay Area with physician-confirmed SLE.

Applying for patient assistance programs, purchasing medications outside the US, requesting lower-cost alternatives, delaying refills, and skipping doses were used to define medication cost concerns, as was having self-reported difficulties affording lupus medications.

PROs were assed via the Patient Health Questionnaire Depression Scale (PHQ-8), Systemic Lupus Erythematosus Activity Questionnaire (SLAQ), and Patient-Reported Outcomes Measurement Information System (PROMIS).

After adjusting for covariates, investigators used liner regression and mixed-effects models to assess cross-sectional and longitudinal associations between PROs and medication cost concerns.

Of the 332 study participants, 91% were women. Mean patient age was 49 years; 34% of patients were Asian, 31% White, 22% Hispanic, and 11% Black.

Investigators found 27% (91 participants) reported medication cost concerns, which were associated with worse PHQ-8 (beta coefficient, 2.7; 95% CI, 1.4-4.0), SLAQ (beta coefficient, 5.9; 95% CI, 4.3-7.6), and PROMIS (beta coefficient for physical function, -4.6; 95% CI, -6.7 to -2.4) scores, after adjusting for covariates (all P <.001).

Specifically, 38 participants reported difficulties affording lupus medications, 31 applied for patient assistance programs, 29 requested lower-cost alternatives to prescribed drugs, 29 delayed refills, 25 skipped doses, and 6 purchased drugs outside the US. Almost half of those reporting medication cost concerns reported more than 1 such concern.

There were no significant between-group differences (with vs without medication cost concerns) in sex, age, race/ethnicity, number of immunomodulatory drugs, income, and self-reported nonadherence.

Investigators found a significant difference in the distribution of self-reported principal insurance. Patients with medication cost concerns were more likely to report Medicare insurance (P <.001). Current treatment with a biologic-containing immunomodulatory regimen was more frequent among participants with cost concerns vs those without (P <.001).

Significant changes in PROs over the 2-year follow-up were not associated with medication cost concerns.

Study limitations included failure to define recall time in questions about medication cost concerns, disease activity not verified by physician assessment, and the possibility of reverse causality.

The study authors concluded, “Uncovering medication cost concerns may point to solutions such as finding lower cost alternatives or opportunities for changes in policy that enable dependable healthcare coverage and reduce out-of-pocket drug costs.”