Publicly Funded Formulary Coverage of Biologic and Synthetic Disease-Modifying Anti-Rheumatic Drugs for Children with Chronic Arthritis in Canada: Are We Doing Enough?

Objectives Biologic and synthetic disease-modifying anti-rheumatic drugs (bDMARD, sDMARD) have transformed the management of inflammatory arthritis, yet pediatric access remains variable across Canada, often requiring special authorization. We aimed to characterize trends and disparities in access to these therapies through publicly funded provincial programs and Non-insured Health Benefits (NIHB) for First Nations/Inuit. We also examined differences in coverage compared to Health Canada (HC) indications. Methods We reviewed all provincial formularies and NIHB program to determine bDMAARD/sDMARD coverage for pediatric and adult inflammatory arthritis relative to HC indications and compared our data to previously published findings from 2012.[1] We surveyed and interviewed 1 academic pediatric rheumatologist from each province to determine ease of access to these drugs. Results More HC indications exist for bDMARD/sDMARD in adults compared to children. In adults, 9x more drugs are listed for ankylosing spondylitis and 6x more for psoriatic arthritis compared to juvenile idiopathic arthritis (JIA) subtypes (Table 1). There are 2x more drugs with HC indications for rheumatoid arthritis than polyarticular JIA. Even when these drugs have a federally approved pediatric indication, NIHB, intended to promote equitable access for disadvantaged populations, only covers half of them (Table 1). NIHB demonstrated greater accessibility overall, with faster approval times and longer renewal periods compared to the provinces. The total number of distinct adult and pediatric bDMARD/sDMARD for inflammatory arthritis indications covered by NIHB and provincial public plans doubled since 2010. However, significant pediatric interprovincial variability is observed, with 7 bDMARDs in Ontario, and 67% of the remaining provinces funding 4 or less drugs (Table 1). The success observed in Ontario reflects strong advocacy efforts and physician-led submissions. All provincial formularies included anti-IL-6 treatment for systemic JIA whereas the Maritimes and Ontario notably also covered anti-IL-1 drugs. Pediatric rheumatologists reported differences in ease of accessing bDMARDs, with approval times under 1 week in Manitoba and Saskatchewan and 1-4 weeks in all provinces except Quebec, which averaged 3-6 months. Renewal intervals were 3 months in Alberta, 6 months then annually in all provinces except Ontario, which reported 1-3 years. Denials occurred in all provinces because of restrictive formularies and nonstandard indications. Table 1. Health Canada–Approved Indications and NIHB/Provincial Publicly Funded bDMARDs/sDIMARDs/Other Drugs for Inflammatory Arthritis . NIHB – Non-Insured Health Benefits; AB – Alberta; BC – British Columbia; MB – Manitoba; NL – Newfoundland and Labrador; NS – Nova Scotia; ON – Ontario; PE – Prince Edward Island; QC – Quebec; SK – Saskatchewan. T-cell inhibitor : ABA – Abatacept, TNFa inhibitor : ADA – Adalimumab: ETA – Etanercept; INF – Infliximab: GOL – Golimumab: CER – Certolizumab Pegol. IL-6 inhibitor : TOC – Tocilizumab; SAR – Sarilumab, IL-1 inhibitor : ANA – Anakinra; CAN – Canakinumab, B-cell inhibitor : RIT – Rituximab, IL-17 inhibitor : SEC – Secukinumab; IXE – Ixekizumab, IL-12/23 inhibitor : UST – Ustekinumab; GUS – Guselkumab, JAK inhibitor : TOF – Tofacitinib; BAR – Baricitinib; UPA – Upadacitinib, PDE4 inhibitor : APR – Apremilast. * ≥2 years, † ≥4 years, ‡ ≥6 years, § ≥40kg Conclusion While bDMARDs have significantly improved JIA outcomes,[2] access to these drugs remains limited compared with adults despite advances since 2010. Substantial interprovincial disparities and inequities were reported in the approval and renewal processes. References [1.] Leblanc CMA. J Rheumatol 2012;39:1875-79. [2.] Adrovic A. Arch Rheumatol 2020;36:146-57.