EP27 The Exeter Biologics Management Plan
Authors: Haigh Richard , Murphy Daniel , Moran Jill 
Published: April 2020

Abstract

Background
The introduction of biologic drugs has been life-changing for our patients, but these drugs are very expensive. Moreover, they are immunosuppressive and are associated with an increased infection risk. Conventional practice is to maintain the same dose long term. An internal audit identified significant drug wastage; £40,000 drug 'wasted' per year by repeat prescription requests, hoarding of supplies and missed doses. Dose reduction could result in cost savings and reduced complications, but this strategy also risks loss of disease control & requires enhanced monitoring.

Methods
We set up a new 'Biologics Managment Plan' Service (BMP) with the following aims: 1. Reduce costs from wastage, 2. Enable patients to confidently reduce dose by introducing a part time nurse and biologics administrator, 3. Assess efficacy, 4. Receive patient feedback. We formulated criteria to ensure eligibility for dose reduction and a dose reduction protocol for each biologic drug. We organised an intensification of follow up, monitoring and support. We maintained close liaison with pharmacy regarding prescription management and vial sharing on Day Case Unit. We fully counselled our BMP patients and subsequently obtained detailed patient feedback using a patient experience measure (PREM), plus free text comments. We examined clinical outcomes including disease activity assessments, occurrence of flares and, where possible, radiological outcomes, in patients with inflammatory arthritis undergoing biologic dose reduction.

Results
82 patients entered our BMP, 48 with rheumatoid arthritis (RA). 70% were able to dose reduce successfully. Mean dose reduction was 43%. For the 48 patients with RA, disease duration, presence of erosive disease nor serological status determined dose reduction outcome. 13 patients lost control of disease with dose reduction, but regained control rapidly with intervention. 2 patients switched biologic drug after a period of poor disease control. There was no progression of erosive disease in 31 RA patients who had follow up X-rays, within 18/12 of dose reduction. Similar outcomes were seen in ankylosing spondylitis (15), psoriatic arthritis (19) and JIA (2) with ∼70% success rate. Our PREM revealed &gt;95% felt involved, had sufficient information, & felt that drug reduction had not caused interference with daily life. All would recommend our project to others. We calculated this project was able to save £269,278.58 in the first 12 months.

Conclusion
It is possible to reduce the dose of biologic drugs in selected patients with inflammatory arthritis in remission. Patients were keen to reduce their drug doses and engaged enthusiastically in the process. Enhanced follow-up and support ensured that patients felt 'looked after' and rapid intervention can manage any loss of control of disease promptly. Significant cost savings can be made. We have begun to determine whether therapeutic drug monitoring can complement this process.

Disclosures
R. Haigh: Honoraria; speaker fees Pfizer. Grants/research support; conference attendance Pfizer, UCB. D. Murphy: None. J. Moran: None.