Variações regionais nos padrões de tratamento e difusão de novas tecnologias incorporadas para o tratamento de artrite reumatoide no Sistema Único de Saúde (SUS)

Abstract

Introduction (with objective): In 2021, the new Clinical Protocol and Therapeutic Guidelines (PCDT) for rheumatoid arthritis (RA) in the Brazilian Unified Health System (SUS) was published [1]. The update incorporated a wider variety of synthetic disease-modifying antirheumatic drugs (DMARDs), biological drugs (DMARDs bio), and target-specific drugs (DMARDs ae). The objective of this study was to explore regional differences in RA treatment prescription patterns in Brazil, before and after the publication of the PCDT. Material and Method: Ecological, retrospective study based on data from Outpatient Procedure Authorization (APAC) for medications for the treatment of RA over a 5-year period surrounding the publication of the PCDT (2019 to 2023). Changes in medication dispensing patterns were assessed by the variation in the proportion of patients who received at least one dose of each drug class each year, by geographic region, comparing the figures verified in 2023 with those of 2019. The percentages were calculated in relation to the number of patients treated in the year, and there may be overlapping treatments for the same patient. Results: A total of 8,076,398 medications for rheumatoid arthritis (RA) were dispensed to 289,188 patients in the Brazilian Unified Health System (SUS) between 2019 and 2023, with 51.4% residing in the Southeast, 23.7% in the South, 14.5% in the Northeast, 6.9% in the Central-West, and 3.4% in the North. All regions showed an increase in the volume of patients treated, with the greatest growth in the North (+50.7%) and the smallest in the Southeast (+30.4%). In 2019, differences were observed in the distribution of treatments between regions: while the South, Northeast, and Southeast showed a predominance of DMARDs (77.8%, 67.2%, and 65.7%), in the North and Midwest, bioDMARDs led (61.7% and 57.8%). In 2023, the use of bioDMARDs decreased in all regions (Northeast -6%, Midwest -13.6%, South -14.4%, North -15.5%, and Southeast -21%). DMARDs showed distinct trends, with a slight reduction in the Midwest (-1.7%), Northeast (-2.7%), and South (-3.7%) regions, and an increase in the North (+5.5%) and Southeast (+5.8%). The impact of incorporating two new DMARDs into the Brazilian Unified Health System (SUS), baricitinib in 2020 and upadacitinib in 2021, was noticeable in all regions, accompanied by an increase in the use of tofacitinib. The Central-West region showed the highest dispensing of DMARDs in 2019 (6.4%) compared to other regions (2-2.7%), being the region with the smallest relative increase in the dispensing of this class (2.5 times). Other regions showed an increase of 4.4 (South, North and Northeast) to 5.1 times (North) in the use of DMARDs, ranging from 9% to 16% of patients in 2023. Less than 1% of patients received immunosuppressants or non-steroidal anti-inflammatory drugs during the period. Conclusions: Regional variability in access to and treatment patterns of diseases, as well as the diffusion of newly incorporated technologies, is a challenge for the SUS. This study observed a general increase in the number of RA patients treated in the Brazilian public health system (SUS) between 2019 and 2023. With the expansion of treatment options in the SUS, DMARDs showed a substantial increase, accompanied by a reduction in the use of DMARDs in all regions.