Comment on prescribing tumor necrosis factor inhibitors


To the Editor:

I agree with Dr. Matteson's editorial (Matteson EL. Need for circumspection in prescribing tumor necrosis factor inhibitors and other biologic response modifiers. Arthritis Rheum [Arthritis Care Res] 2002;47:1–4).

I have noticed that many or most of my patients receiving etanercept do not need the recommended twice-weekly injections. As a rule with these patients, I tell them to try receiving an injection every fourth, and then every fifth day once they have noted improvement. The majority of the patients are fully satisfied with an every fifth-day injection and some receive the injection even less often.

Because etanercept is supposed to circulate as a blocking agent for approximately 96 hours, there is no real need for twice-weekly injections except that twice-weekly might be easier for the patient to remember, and of course will result in a larger drug bill. Patients on an every fifth-day course will receive a total of 73 doses a year; whereas patients on a twice-weekly schedule will receive 104 doses. The cost will be reduced from approximately $15,000 to $10,000 annually by the every-fifth-day dosing.

With regard to infectious complications that seem to be developing more frequently over time, an every fifth day dose schedule may allow the patient to recover resistance to bacterial infections and thus result in fewer complications as well as significant cost savings with little change in efficacy in many or most patients.

Lonnie B. Hanauer MD, FACP*, * Millburn, New Jersey