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. 2025 Nov;31(11):1145–1155. doi: 10.18553/jmcp.2025.31.11.1145

Medication utilization patterns among patients with rheumatoid arthritis and coexisting autoimmune conditions

Jonathan P DeShazo 1,✉, Erick Moyneur 1, Djeneba Audrey Djibo 1, Cheryl N McMahill-Walraven 2, Aaron B Mendelsohn 3, Catherine Lockhart 4
PMCID: PMC12577721  PMID: 41171070

Abstract

BACKGROUND:

Rheumatoid arthritis (RA) is the most common inflammatory joint disease worldwide. T-cell inhibitors, tumor necrosis factor inhibitors, interleukin inhibitors (ILIs), Janus kinase inhibitors, and B-cell depletion therapy are indicated as second-line therapy and are prescribed for other inflammatory autoimmune conditions (ankylosing spondylitis, psoriatic arthritis, psoriasis, Crohn disease, ulcerative colitis) co-occurring in an estimated 7% to 20% of patients with RA but are routinely excluded from RA studies. There is a lack of real-world evidence documenting treatment patterns in the large segment of patients with RA with inflammatory autoimmune comorbidities.

OBJECTIVE:

To describe RA medication utilization patterns among biologic-naive patients, with and without similarly treated comorbidities.

METHODS:

This retrospective cohort study uses administrative health claims from a large national health insurer between 2016 and 2022. Persistence, medication possession ratio (MPR), and utilization patterns were measured for patients with and without similarly treated comorbidities. Differences in means were calculated using a t-test, and Cox proportional hazards regression modeling was used to estimate persistence and hazard ratio (HR).

RESULTS:

A total of 22,946 patients with RA persisted on the index therapy for an average of 368.2 days (SD, 436). MPR varied across drug classes, with ILIs having the highest MPR at 0.95 (SD, 0.10) and B-cell depletion class having the lowest at 0.82 (SD, 0.19). Patients with RA with psoriatic arthritis were more likely to end the episode with therapy gap restart (HR, 1.1; CI, 1.02-1.22), yet patients with RA with psoriasis were less likely to experience a therapy gap restart (HR, 0.91; CI, 0.83-0.99). Among patients with RA initiated on ILIs, those with psoriasis are more likely to stop or switch compared with those without psoriasis (HR, 1.19; CI, 1.02-1.39). Among patients with RA initiated on Janus kinase inhibitors, those with psoriatic arthritis were more likely to stop or switch therapy compared with patients with RA without psoriatic arthritis (HR, 1.27; CI, 1.02-1.59).

CONCLUSIONS:

RA medication utilization varied significantly and may be influenced by comorbidities differently across RA drug classes. More research is needed to understand why therapies like tumor necrosis factor inhibitors persist longer in patients with RA with ulcerative colitis yet are discontinued earlier in patients with psoriatic arthritis.

Plain language summary

Rheumatoid arthritis (RA) is commonly treated with biologics and targeted therapies. Patients with other inflammatory autoimmune comorbidities, such as ankylosing spondylitis, psoriatic arthritis, psoriasis, Crohn disease, and ulcerative colitis, are often not included in clinical studies about RA treatment. This study describes how other inflammatory autoimmune diseases in patients with RA might affect how well patients adhere to RA medications.

Implications for managed care pharmacy

The findings of this study may suggest that some therapies are more ideal for treating patients with RA with co-occurring, inflammatory autoimmune conditions. It emphasizes the need for more research to evaluate adherence patterns and build evidence for comorbidity-optimal RA therapies.

Rheumatoid arthritis (RA) is the most common inflammatory joint disease worldwide.1 Early diagnosis and treatment of RA can slow or stop progression of joint damage in up to 90% of patients, avoiding possible significant and irreversible disability.2,3 There are a variety of treatments available for RA, including conventional disease-modifying antirheumatic drugs (DMARDs), tumor necrosis factor (TNF) inhibitor biologics, non–TNF inhibitor biologics, and Janus kinase (JAK) inhibitors.2,4

The American College of Rheumatology and the United Kingdom’s National Institute for Health and Care Excellence recommend conventional DMARDs as the first line of treatment followed by a stepwise change to more intensive therapy (such as biologics) for those unresponsive or unable to tolerate the first-line therapy.

Despite the recommendation, real-world data suggest prescribers may skip first-line monotherapy DMARDs,5,6 reportedly because of anticipated contraindications, side effects, and intolerance observed in DMARD patients. Therefore, T-cell inhibitors, TNF inhibitors, interleukin inhibitors (ILIs), JAK inhibitors, and B-cell depletion therapy classes, which are indicated as second-line therapies, are frequently being prescribed as a first-line treatment. Subsequently, patients unable to tolerate or who are unresponsive to these therapies ultimately progress through different courses of treatment, either cycling within the same therapy class or switching to a therapy with a different mode of action. Therefore, the length of time a patient with RA remains on a drug may be a reasonable proxy for effectiveness in a clinical setting when other measures are not available.7

The presence of comorbidities is especially relevant to RA treatment owing to their detrimental effect on RA outcomes,8 as well as well-documented interactions with RA treatment effects.9 Inflammatory autoimmune conditions such as ankylosing spondylitis, psoriatic arthritis, psoriasis, Crohn disease, and ulcerative colitis have a different heritability and pathophysiology profile from RA yet occur in an estimated 7% to 20% of patients with RA.10–13 Because of similar bioresponses in inflammatory autoimmune conditions, many RA therapies are also indicated for treating 1 or more of these common comorbidities. Despite their prevalence in the RA population, participants having similarly treated, coexisting, autoimmune inflammatory comorbidities are routinely excluded from RA research studies.14,15 Studies that report them individually generally find the adherence to therapy for RA to be slightly lower compared with therapy for ankylosing spondylitis, and psoriatic arthritis,16,17 but higher than therapy treating ulcerative colitis and Crohn disease.18 However, the combined effect of comorbid conditions on persistence and utilization patterns, particularly in similarly treated comorbidities, is unknown. There is a lack of real-world evidence documenting treatment patterns in the large segment of patients with RA with inflammatory autoimmune comorbidities.

Several studies have documented RA treatment patterns to date, finding inconsistent results.14,16,17,19-23 Real-world data are considered the gold standard for eliciting treatment patterns, yet most of these studies are based on prospective trials24 and only 1 study is based on treatment patterns of a US population.23 Previous work has also indicated that treatment patterns are affected by new therapies entering the market.21 Accordingly, a recent scoping review by Yin, McDermott, and Lockhart concludes that a new large real-world study on treatment patterns of RA therapies is needed by patients and clinicians.24

Given the differences in the guideline recommendations and real-world practices as well as the addition of several new RA therapies in the US market, it is important to capture the current pattern of RA treatment. The purpose of this study was to describe presumed moderate to severe RA medication use and adherence utilization patterns among biologic-naive patients, with and without similarly treated comorbidities. Specifically, we measured persistence, medication possession ratio (MPR), and capture outcome patterns such as discontinuation, medication switch, and therapy restart within RA drug classes using claims data from a large commercially insured population.

Methods

STUDY DESIGN AND SETTING

This is a retrospective, longitudinal cohort study conducted on the Biologics and Biosimilars Collective Intelligence Consortium (BBCIC) Distributed Research Network (DRN), a subset of the Sentinel Distributed Database. The BBCIC DRN includes medical and pharmacy health plan membership, medical and pharmacy health plan eligibility, medical claims, and outpatient pharmacy claims for approximately 37 million patient-years from a large national health insurer, Aetna, a CVS Health company.

STUDY POPULATION

This study cohort included adults diagnosed with RA who had medical and pharmacy coverage and are available for research in the Aetna Sentinel Common Data Model database during the period from January 1, 2016, through December 31, 2022.

Patients were included in the study if they were older than 18 years and had an RA diagnosis prior to receiving one of the study medications. To confirm advanced RA therapy naivety, a patient had to have had no dispenses/infusions of advanced RA therapies during the 183 days prior to the first advanced RA therapy date (index date). Patients were excluded if they did not have continuous medical and pharmacy enrollment 183 days before the index date or during follow-up (Figure 1).

FIGURE 1.

Flowchart of Cohort Inclusion/Exclusion

FIGURE 1

Rheumatoid arthritis medications of interest include tumor necrosis factor inhibitor biologics, B-cell depletion therapies, interleukin inhibitors, Janus kinase inhibitors, and T-cell inhibitors.

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This study used administrative claims data for approximately 37 million patient-years from a large national health insurer, Aetna, a CVS Health company. The data are part of the BBCIC DRN, a subset of the Sentinel Distributed Database, and include medical and pharmacy health plan membership, medical and pharmacy health plan eligibility, medical claims, and outpatient pharmacy claims for Aetna’s nonadministrative services Commercial members and Medicare Advantage members.

ADVANCED RA THERAPY CLASSES

Study groups consisted of advanced RA therapy classes. Thirteen medications indicated for moderate to severe RA were selected for this study and grouped into 5 therapy classes. Classes were T-cell inhibitors, TNF inhibitors, ILIs, JAK inhibitors, and B-cell depletion therapies.

SIMILARLY TREATED COMORBIDITIES

The exposure variables for this study are similarly treated, inflammatory, autoimmune conditions that often co-occur in patients with RA. These conditions include ankylosing spondylitis, psoriatic arthritis, psoriasis, Crohn disease, and ulcerative colitis. We also calculated the combined comorbidity score, which is a comprehensive fusion of the Charlson and Elixhauser measures.25 Comorbidities and the combined comorbidity score were based on International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes captured in claims data during the 183-day period prior to the index date. The list of diagnosis codes is available in Supplementary Tables 5 and 6 (419KB, pdf) (available in online article).

STUDY OUTCOMES

The primary study outcomes are episode persistence, MPR, and utilization patterns discontinuation, switch, and therapy restart.

Persistence was defined as the first dispense date through the last dispense date (prior to discontinue or loss to follow-up), plus the last dispense days supply. Medication dispensing dates and days supply were identified in medical procedure claims and pharmacy claims records using National Drug Code (NDC) numbers and Current Procedural Terminology (CPT) codes. Most advanced RA therapies are covered either by medical plans or by pharmacy plans exclusively, but some (eg, abatacept, certolizumab pegol, golimumab, tocilizumab) may be covered by either mechanism depending on the plan. Because days supply is often missing from medical claims data but present in pharmacy claims, we used a standardized days supply based on the drug label when missing26—the rationale being as more therapies are covered by both medical and pharmacy plans, the alternative practice of excluding infused therapies altogether27–29 becomes more problematic.

See Supplementary Table 1 (419KB, pdf) for a list of medications, drug classes, and standardized days supply.

Persistence was reported as continuous days, 6-month persistence (y/n), 1-year persistence (y/n), and 2-year persistence (y/n). When persistence was greater than days of follow-up, the utilization outcome pattern was considered loss to follow-up and the persistence episode is right censored.

Discontinuation was defined as persistence until a supply gap longer than 1.5 times the standard days supply for injectables and infusions, and a 45-day gap for oral therapy, which is comparable to previous research.16,26,27

A medication switch requires a discontinuation of the first therapy prior to the dispensing of the second therapy. The second therapy may be initiated any time after the last refill/infusion date, including before the therapy supply period is completed.

A therapy restart was defined as starting/continuing the same therapy after a discontinuation before loss to follow-up. Note that persistence of the index therapy can be directly measured for discontinuation, medication switch, and therapy restart outcome patterns because they have a known end date and last days supply. However, persistence was only partly known for loss to follow-up episodes and must be censored. See Figure 2 for a visual reference of medication utilization patterns.

FIGURE 2.

FIGURE 2

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Rheumatoid Arthritis Medication Utilization Patterns

Biosimilars and generics were not considered distinct from their originator therapies. Therefore, any nonmedical switch from a reference biological (originator) to a biosimilar would not be classified as a switch in this study.

Medication dispensing dates and days supply were identified in medical procedure claims and pharmacy claims records using NDC numbers and CPT codes.

Secondary outcomes include MPR, defined as the number of days supplied by the index drug divided by the persistence days, and comorbidity hazard ratio (HR), which is the hazard rate of patients having a comorbidity divided by the hazard rate of patients without the comorbidity.

ANALYSIS

Patients were observed from the index date (ie, the first date of drug initiation) to the end of the study period or loss to follow-up. Descriptive statistics summarized the patient population at the index date and utilization patterns. Means, SDs, and medians were obtained for continuous variables. Counts and percentages were given as categorical variables. Differences in means were calculated using a t-test applying a Bonferroni correction for multiple tests. Crude persistence was estimated using Kaplan-Meier analysis, and Cox proportional hazards regression modeling was used to estimate persistence and HR adjusting for age, sex, and combined comorbidity score. The proportional hazards assumption for a Cox regression model was tested to ensure a nonsignificant global P value. Results are shown as 95% CIs and HRs. All analyses were completed using SAS EG version 8.3 (SAS Institute Inc.).

Results

BASELINE CHARACTERISTICS OF STUDY POPULATION

A total of 22,946 patients with RA and initiating a study drug were included in the analysis. The mean age of all patients was 56.7 years (SD, 14.5), and 73.7% were female. The study population comprised patients receiving TNF inhibitors (14,787; 64.4%), B-cell depletion therapy (2,666; 11.6%), ILIs (2,463; 10.7%), JAK inhibitors (1,324; 5.8%), and T-cell inhibitors (1,706; 7.4%) at baseline. See Supplementary Table 2 (419KB, pdf) for more baseline characteristics of the cohort.

RA TREATMENT PATTERNS AT INDEX

Overall, patients persisted on the index therapy for an average of 368.2 days (SD, 436). Persistence and utilization patterns of the index therapies are displayed in Supplementary Table 3 (419KB, pdf) . The most common utilization pattern for the index therapy was discontinue (38.5%), followed by a therapy restart (28.8%). Of index therapies, 19.2% were switched to other study therapies and 13.5% were censored. Supplementary Table 3 (419KB, pdf) presents treatment patterns by drug class and comorbidity for the index therapy.

PERSISTENCE OF INDEX THERAPY

After adjusting for age, sex, and combined comorbidity score, patients taking B-cell depletion therapy had the highest 6-month persistence rate (0.73; CI, 0.71-0.74), and patients taking B-cell depletion therapy had the highest 2-year persistence rate (0.38; CI, 0.36-.40) (Figure 3). When viewing the survival plots representing persistence, ILIs trailed the others, whereas the B-cell depletion therapy curve was markedly higher.

FIGURE 3.

Persistence by Drug Class

FIGURE 3

BCDT = B-cell depletion therapy; ILI = interleukin inhibitor; JAKI = Janus kinase inhibitor; TCI = T-cell inhibitor; TNFI = tumor necrosis factor inhibitor biologic.

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MPR

Table 1 presents MPR by drug class and by presence of comorbidity. In the overall population, MPR varied across drug class, with ILI having the highest MPR at 0.95 (SD, 0.10) and B-cell depletion class having the lowest at 0.82 (SD, 0.19).

TABLE 1.

MPR by Comorbidity

All TNFI BCDT ILI JAKI TCI
Overall All 0.89 (0.39) 0.88 (0.47) 0.82 (0.19) 0.95 (0.10) 0.93 (0.09) 0.93 (0.09)
Ankylosing spondylitis Y 0.89 (0.16) 0.89 (0.17) 0.85 (0.18) 0.97 (0.07) 0.95 (0.08) 0.94 (0.09)
N 0.89 (0.40) 0.88 (0.49) 0.82 (0.19) 0.95 (0.10) 0.93 (0.09) 0.93 (0.09)
Crohn disease Y 0.86 (1.11)a 0.85 (1.19)a 0.82 (0.20) 0.98 (0.07) 0.92 (0.10) 0.95 (0.07)
N 0.89 (0.30)a 0.88 (0.36)a 0.82 (0.19) 0.95 (0.10) 0.93 (0.09) 0.93 (0.09)
Psoriatic arthritis Y 0.90 (0.15) 0.90 (0.16) 0.86 (0.17) 0.95 (0.11) 0.95 (0.08) 0.93 (0.09)a
N 0.89 (0.41) 0.88 (0.51) 0.82 (0.19) 0.95 (0.10) 0.93 (0.09) 0.95 (0.07)a
Psoriasis Y 0.90 (0.16) 0.89 (0.16) 0.81 (0.21) 0.95 (0.10) 0.94 (0.09) 0.94 (0.08)
N 0.89 (0.41) 0.88 (0.51) 0.83 (0.19) 0.95 (0.10) 0.93 (0.09) 0.93 (0.09)
Ulcerative colitis Y 0.83 (1.53)a 0.81 (1.70)a 0.81 (0.20) 0.98 (0.06)a 0.95 (0.08) 0.94 (0.08)
N 0.89 (0.16)a 0.88 (0.17)a 0.82 (0.19) 0.95 (0.10)a 0.93 (0.09) 0.93 (0.09)
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a

Indicates P < 0.01 difference in MPR between having the comorbidity and not having the comorbidity.

BCDT = B-cell depletion therapy; ILI = interleukin inhibitor; JAKI = Janus kinase inhibitor; MPR = medication possession ratio; N = no; TCI = T-cell inhibitor; TNFI = tumor necrosis factor inhibitor biologic; Y = yes.

SWITCHING

Switching from index therapy to a second therapy occurred in 4,407 patients. Sixty-four percent of patients who switched from a TNF inhibitor class drug initiated a different TNF inhibitor class drug as a second therapy. Except for those indexed on B-cell depletion class, a plurality of patients who switched switched to a TNF inhibitor class as a second therapy. Figure 4 shows a switch matrix for index therapy to second therapy switches.

FIGURE 4.

Switching From Index Therapy to Second Therapy

FIGURE 4

BCDT = B-cell depletion therapy; ILI = interleukin inhibitor; JAKI = Janus kinase inhibitor; TCI = T-cell inhibitor; TNFI = tumor necrosis factor inhibitor biologic.

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ASSOCIATION BETWEEN COMORBIDITIES AND PERSISTENCE

Figure 5 presents the adjusted HR by comorbidities for each drug class. Among patients with RA initiating on TNF inhibitors, those with Crohn disease were less likely to switch or stop (ie, more likely to persist) compared with those without Crohn disease (HR, 0.74; CI, 0.68-0.80). In other words, patients with RA with Crohn disease were approximately 1.3 times more likely to persist compared with patients with RA without Crohn disease. Patients with RA with ulcerative colitis were also less likely to switch or stop TNF inhibitors (HR, 0.89; CI, 0.83-0.96). However, patients with psoriatic arthritis were more likely to switch or stop TNF inhibitors (HR, 1.12; CI, 1.06-1.19).

FIGURE 5.

Association Between Comorbidities and Persistence

FIGURE 5

HR = hazard ratio; Inh. = inhibitor.

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Among patients with RA initiated on ILIs, those with psoriatic arthritis are more likely to stop or switch compared with those without psoriatic arthritis (HR, 1.19; CI, 1.02-1.39). Among patients with RA that initiated on ILIs, those with psoriatic arthritis were more likely to stop or switch therapy compared with patients with RA without psoriatic arthritis (HR, 1.19; CI, 1.02-1.39). Among patients with RA initiated on JAK inhibitors, those with psoriatic arthritis were more likely to stop or switch therapy compared with patients with RA without psoriatic arthritis (HR, 1.27; CI, 1.02-1.59).

ASSOCIATION BETWEEN COMORBIDITIES AND MPR

Looking at all advanced RA therapies together, having Crohn disease and having ulcerative colitis were both associated with a statistically lower MPR compared with not having the comorbidity (Table 1). MPR did not change for those having any comorbidities in the B-cell depletion and JAK inhibitor therapies. Notably, patients taking ILIs with ulcerative colitis had a higher MPR compared with those without ulcerative colitis, suggesting a directional difference from the other associations.

ASSOCIATION BETWEEN COMORBIDITIES AND UTILIZATION PATTERNS

Supplementary Table 4 (419KB, pdf) presents the adjusted comorbidity HRs for each of the utilization patterns. RA index therapies in patients with a codiagnosis of psoriatic arthritis were more likely to conclude with a therapy restart (HR, 1.1; CI, 1.02-1.22) or a switch (HR, 1.20; CI, 1.09-1.32) compared with patients with RA without psoriatic arthritis. Conversely, index therapies in patients with RA with a codiagnosis of psoriasis are less likely to experience a therapy restart pattern (HR, 0.91; CI, 0.83-0.99), compared with patients with RA without psoriasis. Index therapies in patients with RA with a codiagnosis of Crohn disease were less likely to experience a discontinue (HR, 0.77; CI, 0.69-0.85) or therapy restart pattern (HR, 0.87; CI, 0.76-0.99) compared with patients with RA having no diagnosis of Crohn disease.

Discussion

The overall persistence rates in this study were comparable to some prior reports15,19,23,28,29 yet very different from others.16,17,30-32 Most of these studies found higher persistence and lower switch rates compared with our results, but some found the opposite.18,32 Differences may be attributed to various inclusion/exclusion criteria, the 183 days of required follow-up, and outcomes definitions. For example, Alvarez-Madrazo’s study of Scottish adults found that approximately half (52% ankylosing spondylitis, 54% psoriatic arthritis, 48% RA) of patients persisted on their index biologic16 during the 41-month study period.

These persistence rates are higher than those we observed in our cohort but potentially explained by a shorter follow-up period, 2-dose inclusion criteria, and allowing switches in the persistence calculation. A study based in Italy had different persistence results and defined persistence as “maintenance over the last 3 months” and allowed drug-experienced participants.30 In their US-based study, Peter and colleagues found a lower switch rate (9% over 12 months) in their analysis of patients with RA. This could possibly be explained by 3 differences between the studies: (1) they did not consider switching to another treatment with the same mechanism of action as a “switch,” (2) they included nonbiologic DMARDs, which may have different persistence profiles, compared with biologics, and (3) their study population consisted of a single specialty clinic in 1 geographic area.

A key unique aspect of our study is the inclusion of patients with ankylosing spondylitis, psoriatic arthritis, psoriasis, Crohn disease, and ulcerative colitis, which accounted for approximately one-fourth of our sample. The effect of similarly treated conditions on RA therapy utilization does not appear to be consistent among therapies or comorbidities. Of note, effect directionality varied between RA therapy classes and comorbidities, suggesting similarly treated comorbidities may moderate the effectiveness of RA medications differently across RA drug classes. These findings may also suggest that some therapies are better tolerated than others for treating co-occurring, inflammatory autoimmune conditions in patients with RA.

LIMITATIONS

The findings in this study are based on observed health insurance claims. As such, some of the observations may have been skewed because of loss of follow-up. Reasons for loss to follow-up may include disenrollment, or health plan changes, and other reasons not captured. In addition, the underlying reason for discontinuation or switch is unknown. The study is based on one payer population and may not be generalizable to other populations. A standard days supply based on label guidance was applied when days supply was missing. Although most RA medicines have fixed dosing, applying standard days supply may bias results for medical benefit medications.

Additionally, utilization patterns may be impacted by insurance plan elements such as patient cost sharing and formulary/step design. This study focuses on comorbidities “similarly treated” to RA, and some therapies may be indicated for RA as well as comorbidities. We cannot know whether the patient initiated the therapy primarily to treat RA, the comorbidity, or both. Concomitant use of traditional DMARDs may impact unitization patterns but was not captured in this study.

The study required 6 months of coverage prior to the earliest use of one of the study medications, adding some assurance that index use was the first initiation. However, whether the index drug was prescribed primarily to treat RA or one of the similarly treated comorbidities is not known.

The drug classes in this study are imbalanced with respect to the number of therapies within a class and the availability of products during the study period. For example, the TNF inhibitor class includes some of the oldest RA therapies (eg, etanercept and infliximab) as well as one of the newest therapies (certolizumab pegol). There is only 1 therapy in the B-cell depletion therapy and T-cell inhibitor classes, but 5 TNF inhibitors and 4 ILIs. Therefore, some therapies have more in-class switching opportunities during our study period. Longer-acting therapies such as monthly injectables have been shown to contribute to improved adherence and persistence in real-world studies compared with daily and weekly therapies.33–35

Conclusions

In this study, we examined persistence and patterns of utilization outcomes in patients with moderate to severe RA, including those with similarly treated inflammatory autoimmune conditions such as ankylosing spondylitis, psoriatic arthritis, psoriasis, Crohn disease, and ulcerative colitis. Our findings update the real-world usage patterns for US patients during the 2016-2022 time frame, including the market entrance of key new RA therapies.

RA medication utilization patterns varied significantly among the study population by the therapy class and comorbidities. A key finding of this study is evidence of similarly treated conditions moderating the persistence and utilization patterns differently across RA therapy classes. More research is needed to understand why therapies like TNF inhibitors persist longer in patients with RA with ulcerative colitis yet are discontinued earlier in patients with psoriatic arthritis.

Based on the large number of patients with RA with similarly treated comorbidities and the heterogeneous utilization patterns of RA-comorbid-therapy combinations, more research is needed to confirm these results and build evidence for comorbidity-optimal RA therapies.

Disclosures

This study was funded by the Biologics and Biosimilars Collective Intelligence Consortium (BBCIC), who also provided scientific input to the initial study concept. The authors received no other financial support or grants for this research. Dr Lockhart is an employee of the study sponsor.

Acknowledgments

The authors wish to acknowledge the working group for their contributions and expertise in developing this manuscript: Jaclyn Bosco, Anna Chen, Anna Hyde, Ran Jin, Nancy Lin, Junjie Ma, James Marshall, and Kelsey Johnson for editorial support.

Data are not freely available owing to privacy and proprietary restrictions. Additionally, no identifiable private information has been shared with JMCP. This study was determined to not constitute human subjects research and is therefore exempt from institutional review board approval. This study has been conducted according to all legal and regulatory requirements.

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