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IN-DEPTH REVIEWS
Biologic Prescribing Patterns Among Mount Sinai Psoriasis Patients:
Results of a Retrospective Chart Review
Alexa Choy,1 Jonathan Vebman,1 Christopher J. Yao, MPH1,2
1Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY
2University of Rochester School of Medicine and Dentistry, Rochester, NY
Psoriasis is a painful and chronic
inflammatory skin condition that can be
disabling to both the physical and
psychological health of affected patients.1 In
2013, it was reported psoriasis was
prevalent in 7.4 million adults in the United
INTRODUCTION
Introduction: Psoriasis is a painful and chronic inflammatory skin condition that not only
impacts the quality of life of patients but is also a socioeconomic burden due to the cost of
treatment, particularly with biologic treatments.
Objective: The purpose of the study is to understand biologic prescribing patterns among
Mount Sinai psoriasis patients and assess its relationship to insurance policy, which may limit
treatment access.
Methods: This study reviewed randomized, de-identified charts of psoriasis patients in a
nine-physician academic practice at Mount Sinai (New York, United States) with the following
insurers: Aetna, Blue Cross Blue Shield, Empire Blue Cross Blue Shield, Medicare A&B, and
United Healthcare, treated with the following biologics: secukinumab, etanercept,
adalimumab, infliximab, brodalumab, ustekinumab, ixekizumab and guselkumab. A chi-
square test was performed to compare prescribed biologics by insurance company.
Results: Ustekinumab was the most prescribed biologic treatment across all the insurance
plans. There were also disproportionate prescriptions of certain biologics for patients under
particular insurance plans. Etanercept, brodalumab, and infliximab were the least prescribed
biologics.
Conclusion: Results highlight certain patterns in the prescribed biologics of Mount Sinai
patients. Prescribed biologics tend to vary by different insurers. However, ustekinumab was
the most frequently prescribed biologic among all insurers, though it is not the most
efficacious biologic based on PASI responses. Future research should be conducted to
assess how differences in insurance policies (e.g. cost to patient) affect biologic prescribing.
ABSTRACT
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States.2 Psoriasis is also associated with an
increased risk of comorbidities, such as
psoriatic arthritis, Crohn’s disease,
malignancy, psychological/mental illness,
obesity and cardiovascular diseases.3 There
is also a significant socioeconomic burden in
the cost of psoriasis and its treatments.1
Among U.S. adults, 32.1% of those with
restricted prescription medication,
experienced a prominent decline in their
health status.4 Psoriasis currently has no
cure and, therefore, requires extensive and
long-term treatment.1
Though a common and effective treatment
for psoriasis, biologic therapies have higher
costs, compared to other psoriasis
treatments, such as phototherapy and
traditional systematic treatments.10 There
are also differences in efficacy among the
biologics. A recent network meta-analysis
showed brodalumab was significantly more
efficacious than secukinumab, ustekinumab
and etanercept based on PASI responses
after 52 weeks.11 However, little information
concerning insurance policy and access to
biologics is known. One recent survey
in ulcerative colitis found that 219 (43.8%) of
surveyed gastroenterologists experienced
limitations to prescribing biologics. Two of
the most commonly cited prescribing
barriers included patient insurance
restrictions (79.0%) and out-of-pocket costs
(71.7%).12 Thus, the purpose of this study is
to understand biologic prescribing patterns
among Mount Sinai psoriasis patients and
assess its relationship to insurance policy,
which may limit treatment access.
Chart Review
This retrospective study was conducted on
randomized de-identified charts of psoriasis
patients from the medical electronic billing
database, Epic, at the Mount Sinai
Dermatology Department faculty practice,
from nine different dermatologists. The
charts were dated from December 5, 2016
through June 25, 2018. The conducted
review collected charts of psoriasis patients
with the highest frequency insurance plans
at Mount Sinai’s Dermatology Department:
Aetna, Blue Cross Blue Shield (BC/BS),
Empire Blue Cross Blue Shield (Empire
BC/BS), Medicare A&B and United
Healthcare, treated with the following
biologic treatments: ustekinumab,
guselkumab, adalimumab, secukinumab,
ixekizumab, etanercept, brodalumab and
infliximab. Data were collected on patient’s
sex, age, zip code, insurance company and
prescribed biologic.
Statistical Analysis
Statistical analyses were conducted with
Stata Version 15.1 (StataCorp LLC, College
Station, TX, USA). First, we generated
demographic statistics (age, sex, residence)
for patients with each insurance company. A
contingency table chi-square test was
performed for patients with the insurance
plans Aetna, BC/BS, Empire BC/BS,
Medicare A&B, and United Healthcare and
prescribed either adalimumab, ustekinumab
or guselkumab. Secukinumab, etanercept,
infliximab, brodalumab and ixekizumab were
omitted from this contingency table chi-
square test because fewer than 5 patients
had these combinations: Empire BC/BS with
secukinumab, BC/BS with etanercept,
Empire BCBS with etanercept, Aetna with
infliximab, Empire BC/BS with infliximab,
Medicare A&B with infliximab, Aetna with
brodalumab, BC/BS with brodalumab,
Empire BC/BS with brodalumab, United
Healthcare with brodalumab, BC/BS with
ixekizumab and Empire BC/BS with
ixekizumab.
METHODS
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Patient Sample
The study cohort included 210 unique
patients with 579 prescriptions for a biologic
treatment from their dermatologists (Table
1). Ninety-three patients (44.3%) were
female and 117 (55.7%) were male.
Seventy-four patients (35.2%) resided in
Manhattan, 28 (13.3%) in New Jersey and
27 (12.9%) in Brooklyn, while the remaining
81 patients (38.6%) resided in the greater
New York area or other regions of the
United States. The mean age (standard
deviation) was 53.0 (19.3) with the majority
(21.4%) within the age range 61-70.
Biologics prescribed for patients on
different insurance plans
Overall, ustekinumab was the most
commonly prescribed biologic (n=276
[47.7%]) (Table 2). Ustekinumab was also
the most frequently prescribed biologic for
each individual insurance plan: Aetna
(52.0%), BC/BS (61.5%), Empire BC/BS
(34.7%), Medicare A&B (43.9%) and United
Healthcare (44.1%) (Table 2).
There was also a disproportionate amount of
prescriptions for particular biologic
treatments for some insurers. Of the Empire
BC/BS patients, there were 24.5%
adalimumab and 26.5% guselkumab
prescriptions; only 8.2% secukinumab, 4.1%
ixekizumab and 2.0% infliximab
prescriptions, and no prescriptions for
brodalumab. For United Healthcare patients,
22.1% of patients were prescribed
secukinumab, compared to fewer than 10%
of prescriptions for other biologics.
Infliximab, brodalumab and etanercept were
the least prescribed biologics at the
respective frequencies: 12 (2.1%), 17 (2.9%)
and 26 (4.5%) (Table 2). For patients with
Aetna, BC/BS, Empire BC/BS, Medicare
A&B and United Healthcare and prescribed
either ustekinumab, guselkumab or
adalimumab, there was a significant
difference between the number of patients
with the insurance plans and their biologic
prescription (p<0.001).
Table 1. Descriptive statistics of analyzed patients
(n=210).
Variable
Frequency (%)
Sex
Female 93 (44.3)
Male 117 (55.7)
Age (mean ± SD)
54.0 ± 19.3
Age ranges
11-20 6 (2.9)
21-30 19 (9.1)
31-40 43 (20.5)
41-50 22 (10.5)
51-60 28 (13.3)
61-70 45 (21.4)
71-80 30 (14.3)
81-90 16 (7.6)
90-100 1 (0.5)
Region by zip code
Manhattan 74 (35.2)
New Jersey 28 (13.3)
Brooklyn 27 (12.9)
Other 81 (38.6)
RESULTS
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Table 2. Frequency (%) of biologics prescribed for patients on different insurance plans* Insurance
companies studies were: Aetna, Blue Cross Blue Shield (BC/BS), Empire Blue Cross Blue Shield (Empire BC/BS),
Medicare A&B and United Healthcare with the biologics: ustekinumab, guselkumab, adalimumab, secukinumab,
ixekizumab, etanercept, brodalumab and infliximab. The contingency table chi-square test for performed for
patients with the insurance plans Aetna, BC/BS, Empire BC/BS, Medicare A&B and United Healthcare and
prescribed either ustekinumab, guselkumab or adalimumab was statistically significant, indicating there is a
difference between number of patients with the aforementioned insurance plans and their biologic prescription
(p<0.001).
*Specific insurance information for each plan was not available to reference specific policies for biologic access.
High number of prescriptions
Though this study originally intended to
identify prescribing patterns among different
insurers, the most significant outcome was
identifying ustekinumab as the most
frequently prescribed biologic among all
insurers and within the entire cohort.
Interestingly, ustekinumab is not as effective
as some other biologics. For instance, Yao
and Lebwohl (2019) analyzed the time of
onset of antipsoriatic drugs, including
popular, available biologics for psoriasis.5
That study analyzed two outcomes: time for
25% of patients to achieve a 75%
improvement from baseline PASI (PASI 75)
and time for patients to achieve a mean 50%
improvement from baseline PASI (PASI 50).
Ustekinumab performed slower than
brodalumab, ixekizumab, secukinumab,
infliximab, and adalimumab in both study
outcomes. Additionally, results from a long-
term (52 week) efficacy meta-analysis of
biologic PASI responses also determined
brodalumab and secukinumab both
responded with higher proportions of PASI
75, PASI 90 and PASI 100 than
ustekinumab.11
Though ustekinumab is a less efficacious
biologic treatment compared to some of the
other common antipsoriatic biologics, it is
the most frequently prescribed within this
study cohort. At Mount Sinai, because
ustekinumab is only prescribed every 3
months, it is administered during the
patients’ office visit and therefore qualifies
as a medical benefit. Because most patients
have co-insurance, with supplementary
insurance to pay their copayments, their in-
Insurance Company (%)
Biologic Aetna BC/BS Empire BC/BS Medicare United Total
Ustekinumab 64 (52.0) 56 (61.5) 17 (34.7) 83 (43.9) 56 (44.1) 276 (47.7)
Guselkumab 19 (15.5) 7 (7.7) 13 (26.5) 23 (12.2) 11 (8.7) 73 (12.6)
Adalimumab 9 (7.3) 8 (8.8) 12 (24.5) 16 (8.5) 9 (7.1) 54 (9.3)
Secukinumab 7 (5.7) 9 (9.9) 4 (8.2) 22 (11.6) 28 (22.1) 70 (12.1)
Ixekizumab 13 (10.6) 4 (4.4) 2 (4.1) 24 (12.7) 8 (6.3) 51 (8.8)
Etanercept 8 (6.5) 0 (0.0) 0 (0.0) 10 (5.3) 8 (6.3) 26 (4.5)
Brodalumab 3 (2.4) 1 (1.1) 0 (0.0) 10 (5.3) 3 (2.4) 17 (2.9)
Infliximab 0 (0.0) 6 (6.6) 1 (2.0) 1 (0.5) 4 (3.2) 12 (2.1)
Total (%) 123 (100.0) 91 (100.0) 49 (100.0) 189 (100.0) 127 (100.0) 579 (100.0)
DISCUSSION
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office treatments are covered as part of the
office visit and therefore the patient has no
out-of-pocket expenses. However, the other
biologics are considered a pharmacy benefit
because they are self-administered;
therefore, the patient must pay a copayment
out-of-pocket every time their prescription is
renewed. Thus, because ustekinumab may
end up being less costly for the patient due
to these insurance policies, doctors may
choose to prescribe it more often.
Low number of prescriptions
The low number of prescriptions for
infliximab, brodalumab and etanercept was
also examined. Although specific reasons
for biologic selection was not identified in the
charts, potential explanations are plausible.
Infliximab is given by infusion and therefore
may be unfavorable to dermatologists. It is
also plausible brodalumab is not often
prescribed by dermatologists because of the
package insert stating brodalumab is
associated with suicidal ideations.6
Etanercept was likely limited in prescriptions
because of its lower efficacy relative to other
agents. Low and high doses of etanercept
are the slowest acting antipsoriatic biologics
compared to secukinumab, etanercept,
adalimumab, infliximab, brodalumab,
ustekinumab, and ixekizumab, making it the
least effective of the all the biologics in this
study.5
Limitations
There are limitations to this study. Data only
included Mount Sinai patients and were
therefore not representative of other
hospitals or regions. Mount Sinai
Dermatology faculty practice also does not
include Medicaid patients, who are seen in
the resident clinic; therefore, the results of
the study do not factor in the Medicaid
population. It is also not definitive whether a
dermatologist prescribed a certain drug due
to insurance coverage restrictions or for
other reasons. For example, pre-existing,
chronic co-morbidities could be a
determining factor for why a patient would
be prescribed a particular biologic (and not
necessarily the most efficacious biologic).9
Another factor is ixekizumab was only
approved on December 1, 2017,7 and
guselkumab was only approved on July 13,
2017,8 which may have skewed the number
of ixekizumab and guselkumab prescriptions
to a lower frequency because the study
collected charts that began on December
5th, 2016. Nonetheless, although
ixekizumab and guselkumab were approved
last, the number of prescriptions for these
two treatments still surpass those of
infliximab, brodalumab and etanercept. Data
on compliance were not collected, which
may influence clinical outcomes or biologic
treatment preference. We were also unable
to obtain information regarding the tiering
system of each insurance company, which
would have provided information about how
each individual insurer affects choice in
biologic. Also, data were not collected on
any fees charged by Mount Sinai for
injections or subcutaneous injection training.
Lastly, some patients may have had a
copayment assistance program, in which the
drug company would have covered any
pharmacy benefit out-of-pocket expenses,
thus, newer biologics could be obtained for
very little costs. Insurance company
coverage would, in turn, not have affected
the patient’s prescription.
The results of our study highlight certain
patterns and discrepancies among biologic
prescriptions for Mount Sinai psoriasis
patients. Though prescribed biologics vary
among insurers, ustekinumab was the most
CONCLUSION
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March 2020 Volume 4 Issue 2
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frequently prescribed biologic among all
insurers, though it is not the most efficacious
based on PASI responses. Future research
should be conducted to assess how
differences in insurance policies (e.g. cost to
patient) affect biologic prescribing.
Conflict of Interest Disclosures: None
Funding: None
Corresponding Author:
Christopher J. Yao, MPH
University of Rochester School of Medicine and
Dentistry, 601 Elmwood Avenue, Box 62, Rochester,
NY, 14642
Phone: 917-817-2241
Email: chrisyao@sas.upenn.edu
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http://apps.who.int/iris/bitstream/handle/10665/20
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2. Rachakonda, T. D., Schupp, C. W., & Armstrong,
A. W. (2014). Psoriasis prevalence among adults
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3. Kaushik, S. B., & Lebwohl, M. G. (2019).
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mailto:chrisyao@sas.upenn.edu
http://apps.who.int/iris/bitstream/handle/10665/204417/9789241565189_eng.pdf?sequence=1
http://apps.who.int/iris/bitstream/handle/10665/204417/9789241565189_eng.pdf?sequence=1
https://www.accessdata.fda.gov/drugsatfda_docs/rems/Siliq_2017-06-08_Full.pdf
https://www.accessdata.fda.gov/drugsatfda_docs/rems/Siliq_2017-06-08_Full.pdf
https://www.psoriasis.org/advance/fda-approves-taltz-psoriatic-arthritis
https://www.psoriasis.org/advance/fda-approves-taltz-psoriatic-arthritis
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