An overview of economic evaluations for drugs used in rheumatoid arthritis : focus on tumour necrosis factor-alpha antagonists

Cost-utility analysis of treatment options after initial tumor necrosis factor inhibitor therapy discontinuation in patients with rheumatoid arthritis

BACKGROUND: For patients with rheumatoid arthritis (RA) who discontinued initial treatment with tumor necrosis factor inhibitor (TNFi), 2 approaches are commonly used: cycling to another TNFi or switching to a drug with another mechanism of action. Currently, there is no consensus on which approach to use first. A report from the IBM MarketScan Research administrative claims database showed adalimumab (cycling strategy) and abatacept (switching strategy) were more commonly prescribed after the first TNFi discontinuation. OBJECTIVE: To evaluate the cost-utility of adalimumab versus abatacept in patients with RA whose initial TNFi therapy failed. METHODS: A probabilistic cost-utility microsimulation state-transition model was used. Our target population was commercially insured adults with RA, the time horizon was 10 years, and we used a payer perspective. Patients not responding to adalimumab or abatacept were moved to the next drug in a sequence of 3 and, finally, to conventional synthetic therapy. Incremental cost-utility ratios (2016 USD per quality-adjusted-life-year gained [QALY)] were calculated. Utilities were derived from a formula based on the Health Assessment Questionnaire Disability Index and age-adjusted comorbidity score. RESULTS: Switching to abatacept after the first TNFi showed an incremental cost of just more than $11,300 over 10 years and achieved a QALY benefit of 0.16 compared with adalimumab. The incremental cost-effectiveness ratio was $68,950 per QALY. Scenario analysis produced an incremental cost-effectiveness ratio range of $44,573 per QALY to $148,558 per QALY. Probabilistic sensitivity analysis showed that switching to abatacept after TNFi therapy failure had an 80.6% likelihood of being cost-effective at a willingness-to-pay threshold of $100,000 per QALY. CONCLUSIONS: Switching to abatacept is a cost-effective strategy for patients with RA whose discontinue initial therapy with TNFi. DISCLOSURES: Funding for this project was provided by a Rheumatology Research Foundation Investigator Award (principal investigator: Maria A. Lopez-Olivo). Karpes Matusevich's work was supported by a Doctoral Dissertation Research Award from the University of Texas, School of Public Health Office of Research. Lal reports competing interests outside of the submitted work (employed by Optum). Suarez-Almazor reports competing interests outside of the submitted work (consulting fees from Pfizer, AbbVie, Eli Lilly, Agile Therapeutics, Amag Pharmaceuticals, and Gilead). Chan, Swint, and Cantor have nothing to disclose.

Anti-Arthritic Effect of Garcinol Enriched Fraction Against Adjuvant Induced Arthritis

Background:

Garcinia indica also known as kokum is used in traditional system of medicine for relieving inflammation and rheumatic pain. Garcinol, a benzophenone obtained from its fruit rind is reported to have anti-inflammatory effect via modulating arachidonic acid metabolism, suppressing iNOS expression, NF-κB activation and COX-2 expression. It has also been studied for antioxidant and anti-cancer activity. Apart from these, few patents claim that garcinol also has anti-obesity and hepatoprotec-tive effect and has a potential to be used for the treatment of renal disorders, endometriosis and cardiac dysfunction.

Objective:

Garcinol Enriched Fraction (GEF) from the fruit rind of Garcinia indica should be effective in the treatment of arthritis, one of the chronic inflammatory disorder owing to its anti-inflammatory property as indicated by earlier experiments.

Methods:

GEF was prepared from the fruit rind of Garcinia indica and quantified using LC-MS/MS. It was found to contain 89.4% w/w of garcinol. GEF was evaluated at the dose of 10mg/kg for its efficacy against Complete Freund’s Adjuvant (CFA) induced arthritis in Wistar albino rats. Paw volumes of both sides were measured by Plethysmometer and body weight was recorded on 0, 1, 5, 12 and 21^st day. The hyperalgesic response was also measured by motility test and stair climbing test.

Results:

GEF showed a significant reduction in paw swelling (p < 0.0001) and arthritis index (p < 0.0001) exhibiting anti-inflammatory potential. It also improves the motility and stair climbing ability of experimental animals (p < 0.05), thus reducing hyperalgesia.

Conclusion:

Garcinol enriched fraction shows anti-arthritic activity in experimental animals.

Lysyl oxidase is involved in synovial hyperplasia and angiogenesis in rats with collagen‑induced arthritis

Lysyl oxidase (LOX) serves an important role in remodeling the extracellular matrix and angiogenesis in various types of cancer; however, whether LOX is involved in the pathogenesis of rheumatoid arthritis remains unknown. In order to investigate this in the present study, β-aminopropionitrile, an inhibitor of LOX, was injected intraperitoneally into rats with type II collagen-induced arthritis (CIA). Subsequently, synovial hyperplasia was examined by hematoxyl in and eosin staining, and the microvascular density (MVD) and expression levels of LOX, matrix metalloproteinase (MMP)-2 and MMP-9 in the synovial membrane and fluid were determined by immunohistochemistry and ELISA, respectively. The enzyme activity of LOX was evaluated by the Amplex Red Hydrogen Peroxide method. The results demonstrated an increased amount of rough synovial membranes, higher MVD in these membranes and more synovial cell layers in CIA rats compared with in the control rats. In addition, higher enzymatic activity of LOX and higher expression levels of MMP-2 and MMP-9 were revealed in CIA rats compared with in the control rats. Notably, β-aminopropionitrile inhibited paw swelling and the decreased the arthritis index, the MVD in the synovial membranes and the expression levels of MMP-2 and MMP-9. Furthermore, the expression level of LOX in the synovial membranes was positively associated with the MVD and the expression levels of MMP-2 and MMP-9, suggesting that LOX promotes synovial hyperplasia and angiogenesis and that LOX may be a potential therapeutic target for rheumatoid arthritis.

Economic evaluation of anti-TNF agents for patients with rheumatoid arthritis in Greece

Objectives

We aimed to estimate the total mean annual treatment cost of different therapy options for patients with moderate-to-severe rheumatoid arthritis (RA) in Greece.

Methods

A cost-minimization approach was adopted. An economic model was developed to estimate the direct costs of the three widely used treatments within a 1-year time horizon, from a health care payer perspective, either for new or for existing patients. Data on resource use, dose escalation, and frequency of therapy were based on a nationwide field survey of rheumatologists. Other analyses were also undertaken based on evidence from the literature. Total cost comprised the cost of drugs, administration, and hospital day care visits. Unit cost data were obtained from the price bulletin and the government gazettes issued by the Ministry of Health. Due to the short time horizon of the study, the cost was not discounted.

Results

The mean annual total cost per new (or per existing) responder patient on etanercept was estimated at €9,845 (€9,840), and the total cost on etanercept/methotrexate (MTX) was estimated at €9,857 (€9,852). Therapy with etanercept had lower annual cost relative to adalimumab and infliximab. On an annual basis, it was estimated that the difference between etanercept monotherapy and adalimumab monotherapy was €544 (€1,323). Similarly, the difference between etanercept/MTX and infliximab/MTX was €1,871 (€1,490) and €543 (€1,323), respectively, relative to adalimumab/MTX. Results remained constant under other scenario analyses undertaken.

Conclusion

In the real-life practice setting in Greece, where dose intensity and frequency differences occur, etanercept alone or in combination with MTX, if prescribed as per label, represents the option with lower annual cost per patient when compared with adalimumab or infliximab in patients with RA. These results hold true as long as the assumptions and data used in the analysis remain stable and may alter if any of the underlying parameters, such as drug price, change.

A novel histone deacetylase 6-selective inhibitor suppresses synovial inflammation and joint destruction in a collagen antibody-induced arthritis mouse model

AIM

To investigate the effects of Tubastatin A, a selective histone deacetylase-6 inhibitor, on synovial inflammation and joint destruction in a collagen antibody-induced arthritis (CAIA) mouse model.

METHODS

Collagen antibody-induced arthritis mice were given daily intraperitoneal injections of various concentrations of Tubastatin A (0, 10, 50, 100 mg/kg). The clinical score and paw thickness were measured. Mice were sacrificed on day 15, and the expression of tumor necrosis factor (TNF)-α, interleukin (IL)-1 and IL-6 in the serum were analyzed using enyme-linked immunosorbent assay (ELISA). Two pathologists independently measured the synovitis score. Micro-computed tomography (CT) scans of the joints were performed to quantify joint destruction. The expression of IL-6 from human fibroblast-like synoviocytes (FLSs) after incubation with various doses of Tubastatin A (0, 0.75, 1.5, 3 μmol/L) was measured using ELISA.

RESULTS

The clinical arthritis score was significantly attenuated and paw thickness was lower in the group treated with 100 mg/kg Tubastatin A compared with those treated with vehicle alone. The synovitis score was significantly reduced in the 100 mg/kg Tubastatin A-treated group compared with the control group. Micro-CT showed that quantitative measures of joint destruction were significantly attenuated in the 100 mg/kg Tubastatin A-treated group compared with the control. The expression of IL-6 in the sera was lower in the mice treated with Tubastatin A compared with the control. The expression of IL-6 in human FLSs decreased dose-dependently after incubation with Tubastatin A without affecting cell viability.

CONCLUSIONS

Tubastatin A successfully ameliorated synovial inflammation and protected against joint destruction in CAIA mice, at least in part, by modulating IL-6 expression.

How to select the right cost-effectiveness model? : A systematic review and stepwise approach for selecting a transferable health economic evaluation model for rheumatoid arthritis

OBJECTIVE

In the current study, we propose an approach for selection of a model that is transferable to a specific decision-making context (in this case, the Netherlands), using the case of rheumatoid arthritis (RA). The objectives of this study were (a) to perform a systematic literature review to identify existing health economic evaluation models for economic evaluation of disease-modifying antirheumatic drugs (DMARDs) in RA; and (b) to test the appropriateness of a stepwise model-selection process.

METHODS

First, we searched Medline and Embase to identify relevant studies in the English language, published between 1 January 2002 and 31 August 2012. From the included studies, all unique models were identified. Second, we applied a multi-step approach to model selection. Models that did not meet all minimal methodological and structural requirements based on the Outcome Measures in Rheumatology (OMERACT) criteria were excluded. Next, models were assessed on the basis of their fit when transferred to the Dutch health care setting. The criteria for model fit were transferability factors, as published by Welte et al., after exclusion of those that were deemed transferable by simple adaptation. Finally, the remaining models underwent a general quality check using the Philips checklist. Models showing good fit and high quality were considered to be transferable to the Dutch health care setting, using simple adaptation.

RESULTS

The systematic literature search identified 498 articles, which included 33 unique health economic evaluation models. Only six models passed the minimal methodological and structural requirements. Two of these models had an imperfect transferability fit to the Dutch health care setting, according to the Welte method. The remaining four models were, according to the Philips method, of good quality and were expected to be transferable by a simple adaptation.

CONCLUSION

This study introduces a stepwise approach for selecting health economic evaluation models that are transferable by a simple adaptation. The approach seems feasible and can be applied in various therapeutic areas, provided that the minimal methodological and structural requirements are defined accordingly. Availability of health economic evaluation models coupled with structured model selection could improve the efficiency, quality and comparability of health economic research.

Tubastatin, a selective histone deacetylase 6 inhibitor shows anti-inflammatory and anti-rheumatic effects

Epigenetic modifications represent a promising new approach to modulate cell functions as observed in autoimmune diseases. Emerging evidence suggests the utility of HDAC inhibitors in the treatment of chronic immune and inflammatory disorders. However, class and isoform selective inhibition of HDAC is currently favored as it limits the toxicity that has been observed with pan-HDAC inhibitors. HDAC6, a member of the HDAC family, whose major substrate is α-tubulin, is being increasingly implicated in the pathogenesis of inflammatory disorders. The present study was carried out to study the potential anti-inflammatory and anti-rheumatic effects of HDAC6 selective inhibitor Tubastatin. Tubastatin, a potent human HDAC6 inhibitor with an IC50 of 11 nM showed significant inhibition of TNF-α and IL-6 in LPS stimulated human THP-1 macrophages with an IC50 of 272 nM and 712 nM respectively. Additionally, Tubastatin inhibited nitric oxide (NO) secretion in murine Raw 264.7 macrophages dose dependently with an IC50 of 4.2 μM and induced α-tubulin hyperacetylation corresponding to HDAC6 inhibition in THP-1 cells without affecting the cell viability. Tubastatin showed significant inhibition of paw volume at 30 mg/kg i.p. in a Freund's complete adjuvant (FCA) induced animal model of inflammation. The disease modifying activity of Tubastatin was also evident in collagen induced arthritis DBA1 mouse model at 30 mg/kg i.p. The significant attenuation of clinical scores (~70%) by Tubastatin was confirmed histopathologically and was found comparable to dexamethasone (~90% inhibition of clinical scores). Tubastatin showed significant inhibition of IL-6 in paw tissues of arthritic mice. The present work has demonstrated anti-inflammatory and antirheumatic effects of a selective HDAC6 inhibitor Tubastatin.

Comparative effectiveness of nonbiologic versus biologic disease-modifying antirheumatic drugs for rheumatoid arthritis

OBJECTIVE

To evaluate the comparative effectiveness of nonbiologic disease-modifying antirheumatic drugs (DMARD) versus biologic DMARD (bDMARD) for treatment of rheumatoid arthritis (RA), using 2 common analytic approaches.

METHODS

We analyzed change in Clinical Disease Activity Index (CDAI) scores in patients with RA enrolled in a US-based observational registry from 2001 to 2008 using multivariable (MV) regression and propensity score (PS) matching. Among patients who initiated treatment with a nonbiologic DMARD (n = 1729), we compared patients who switched to, or added, another nonbiologic (n = 182) or a bDMARD (n = 342) at 5, 9, and 24 months after treatment change.

RESULTS

Both analytic approaches showed that patients switching to or adding another nonbiologic DMARD demonstrated improvement across 9 and 24 months (both p < 0.001). Both approaches also demonstrated greater improvement in CDAI among recipients of bDMARD relative to a second nonbiologic DMARD at 5 months (p < 0.02). The MV regression approach upheld these results at 9 and 24 months (p < 0.03). In contrast, the PS-matching approach did not show a sustained advantage with bDMARD at these later timepoints, possibly because of lower statistical power and/or lower baseline disease activity in the PS-matched cohort.

CONCLUSION

Patients in both treatment groups generally experienced lower CDAI scores across time. Patients switching to bDMARD demonstrated greater improvement than patients switching to nonbiologic DMARD with both analytic approaches at 5 months. Relative advantages with bDMARD were observed at 9 and 24 months only with MV regression. These analyses provide a practical example of how findings in comparative effectiveness research can diverge with different methodological approaches.

Trends in the first decade of 21st century healthcare utilisation in a rheumatoid arthritis cohort compared with the general population

Purpose

To study 21st century trends in healthcare utilisation by patients with rheumatoid arthritis (RA) compared with the general population.

Methods

Observational cohort study. Using Swedish healthcare register data, we identified 3977 Region Skåne residents (mean age in 2001, 62.7 years; 73% women) presenting with RA (International Classification of Diseases-10 codes M05 or M06) in 1998–2001. We randomly sampled two referents from the general population per RA patient matched for age, sex and area of residence. We calculated the year 2001–2010 trends for the annual ratio (RA cohort/referents) of the mean number of hospitalisations and outpatient clinic visits.

Results

By the end of the 10-year period, 62% of patients and 74% of referents were still alive and resident in the region. From 2001 to 2010, the ratio (RA cohort/referents) of the mean number of hospitalisations for men and women decreased by 27% (p=0.01) and 28% (p=0.004), respectively. The corresponding decrease was 29% (p=0.005) and 16% (p=0.004) for outpatient physician care, 34% (p=0.009) and 18% (p=0.01) for nurse visits, and 34% (p=0.01) and 28% (p=0.004) for physiotherapy. The absolute reduction in number of hospitalisations was from an annual mean of 0.79 to 0.69 in male patients and from 0.71 to 0.59 in female patients. The corresponding annual mean number of consultations in outpatient physician care by male and female RA patients changed from 9.2 to 7.7 and from 9.9 to 8.7, respectively.

Conclusions

During the first decade of the 21st century, coinciding with increasing use of earlier and more active RA treatment including biological treatment, overall inpatient and outpatient healthcare utilisation by a cohort of patients with RA decreased relative to the general population.

Cost-effectiveness of biologic treatment for rheumatoid arthritis in clinical practice: an achievable target?

The burden of illness of rheumatoid arthritis (RA) falls on patients, families and society through the direct costs, indirect costs, and intangible costs. A large number of RA cost-of-illness studies have been performed in recent decades with discrepant results due to patient heterogeneity, and different health-care organization, employment rate or social support, job opportunities, and methodologies used to calculate the costs. The greatest burden of RA is the indirect and the intangible costs, but how to estimate them remains controversial. The systematic use of traditional disease modifying anti rheumatic drugs has changed the evolution of the disease. However, a considerable improvement in the management of RA has been obtained since the advent of biologic response modifiers. The use of these drugs, which have demonstrated greater efficacy than conventional therapies, have tripled the direct costs of RA, which rose from about € 4000 to roughly € 12,000, in a period of five years, from 2000 to 2005. The present paper is aimed to examine the effects of this change in therapeutic strategy.

Anti-inflammatory and anti-arthritic activities of 3,4-dihydro-2,2-dimethyl-2H-naphthol[1,2-b]pyran-5,6-dione (β-lapachone)

OBJECTIVE AND DESIGN

The purpose of this study was to evaluate the anti-inflammatory and anti-arthritic activities of 3,4-dihydro-2,2-dimethyl-2H-naphthol[1,2-b]pyran-5,6-dione (β-lapachone; β-lap) and to elucidate its probable mode of action.

METHODS

Carrageenan-induced paw edema, cell migration evaluation and production of pro-inflammatory cytokines tumor necrosis factor (TNF)-α, interleukin (IL)-6 and nitric oxide were used for this study. Freund's complete adjuvant (FCA)-induced arthritis was used as a model of chronic inflammation. β-Lap was tested in doses of 40 and 60 mg/kg, orally.

RESULTS

In the paw edema test, the dose of 60 mg/kg gave a higher percentage inhibition of edema (49.3 %) than control. β-Lap inhibited neutrophil migration and reduced concentrations of TNF-α, IL-6 and NO in peritoneal exudates of animals with peritonitis. In the arthritis test, β-lap inhibited edema and NO production in the serum of treated animals.

CONCLUSION

Significant anti-inflammatory and anti-arthritic activities were observed in animals treated with β-lap. The effects of β-lap can be attributed in part to immunomodulation with reduction of pro-inflammatory cytokines and NO.

Histone deacetylase inhibitors as suppressors of bone destruction in inflammatory diseases

OBJECTIVES

Despite progress in developing many new anti-inflammatory treatments in the last decade, there has been little progress in finding treatments for bone loss associated with inflammatory diseases, such as rheumatoid arthritis and periodontitis. For instance, treatment of rheumatic diseases with anti-tumour necrosis factor-alpha agents has been largely successful in reducing inflammation, but there have been varying reports regarding its effectiveness at inhibiting bone loss. In addition, there is often a delay in finding the appropriate anti-inflammatory therapy for individual patients, and some therapies, such as disease modifying drugs, take time to have an effect. In order to protect the bone, adjunct therapies targeting bone resorption are being developed. This review focuses on new treatments based on using histone deacetylase inhibitors (HDACi) to suppress bone loss in these chronic inflammatory diseases.

KEY FINDINGS

A number of selected HDACi have been shown to suppress bone resorption by osteoclasts in vitro and in animal models of chronic inflammatory diseases. Recent reports indicate that these small molecules, which can be administered orally, could protect the bone and might be used in combination with current anti-inflammatory treatments.

SUMMARY

HDACi do have potential to suppress bone destruction in chronic inflammatory diseases including periodontitis and rheumatoid arthritis.

A population-based study of health-care resource use among infliximab users

OBJECTIVES

We sought to describe the characteristics of health-care utilization (HCU) among patients with Crohn's disease using infliximab (IFX).

METHODS

Using the University of Manitoba Inflammatory Bowel Disease Epidemiology Database (UMIBDED), we extracted all subjects with newly prescribed IFX, newly prescribed purine analogs (azathioprine, AZA) (without IFX), newly prescribed steroids (Ster) (without IFX or purine analogs) after 2001, and those not prescribed any of these drugs (ND). All of the subjects must have had HCU data available for 5 years before initial prescription and for 3 years afterward. We analyzed the number of physician visits, hospital visits, and surgeries.

RESULTS

IBD-associated physician visits were consistently higher for IFX, both pre- and post-initial dosing, although overall physician visits were similar between IFX, AZA, and Ster. There was a steep rise in hospitalizations in the 6 months before initial prescription of IFX, AZA, or Ster, and hospitalizations were higher in the IFX cohort until 18-24 months after the first prescription, at which point levels fell to those evident 2-5 years before initiating IFX and to levels in the other drug groups. Likelihood of surgery post-dosing was greater in IFX than in AZA or ND for up to 36 months but was not different than Ster.

CONCLUSIONS

In a "step-up" approach to IFX use, it takes 2 years for the physician visits to reduce to 2-year pre-dosing rates and 18-24 months to reach hospitalization rates at 2 years pre-dosing and hospitalization rates of the AZA and Ster groups. Surgical rates to 3 years post-dosing were still higher than in AZA or ND groups.

Comparison of the Psoriatic Arthritis Quality of Life (PsAQoL) questionnaire, the functional status (HAQ) and utility (EQ-5D) measures in psoriatic arthritis: results from a cross-sectional survey

OBJECTIVES

To compare the Psoriatic Arthritis Quality of Life (PsAQoL) instrument, the Health Assessment Questionnaire (HAQ) as a measure of functional status, and the generic health status (utility) measure the EuroQoL (EQ-5D) in terms of ability to assess disease severity in psoriatic arthritis (PsA).

METHODS

The differences between known groups and correlations of the PsAQoL, the HAQ and the EQ-5D with clinical measures were analysed in a sample of 183 PsA patients.

RESULTS

Different severities of PsA determined by known groups were distinguished well by all three questionnaires; more severe disease was associated with significantly worse values of the instruments. The correlations revealed a strong relationship between each of the measures, and with the patients' pain on the visual analogue scale (VAS), the patient global VAS, and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and a weak relationship with the disease duration and the Psoriasis Area Severity Index (PASI). The PsAQoL also correlated strongly with the 28-joint Disease Activity Score (DAS28).

CONCLUSIONS

The PsAQoL, the HAQ, and the EQ-5D are able to distinguish well across levels of PsA severity.

Development of a population-based microsimulation model of osteoarthritis in Canada

OBJECTIVES

The purpose of the study was to develop a population-based simulation model of osteoarthritis (OA) in Canada that can be used to quantify the future health and economic burden of OA under a range of scenarios for changes in the OA risk factors and treatments. In this article we describe the overall structure of the model, sources of data, derivation of key input parameters for the epidemiological component of the model, and preliminary validation studies.

DESIGN

We used the Population Health Model (POHEM) platform to develop a stochastic continuous-time microsimulation model of physician-diagnosed OA. Incidence rates were calibrated to agree with administrative data for the province of British Columbia, Canada. The effect of obesity on OA incidence and the impact of OA on health-related quality of life (HRQL) were modeled using Canadian national surveys.

RESULTS

Incidence rates of OA in the model increase approximately linearly with age in both sexes between the ages of 50 and 80 and plateau in the very old. In those aged 50+, the rates are substantially higher in women. At baseline, the prevalence of OA is 11.5%, 13.6% in women and 9.3% in men. The OA hazard ratios for obesity are 2.0 in women and 1.7 in men. The effect of OA diagnosis on HRQL, as measured by the Health Utilities Index Mark 3 (HUI3), is to reduce it by 0.10 in women and 0.14 in men.

CONCLUSIONS

We describe the development of the first population-based microsimulation model of OA. Strengths of this model include the use of large population databases to derive the key parameters and the application of modern microsimulation technology. Limitations of the model reflect the limitations of administrative and survey data and gaps in the epidemiological and HRQL literature.

Pattern and predictors of the initiation of biologic agents for the treatment of rheumatoid arthritis in the United States: an analysis using a large observational data bank

OBJECTIVE

The aim of this study was to identify factors associated with the initiation of biologic agents for the treatment of rheumatoid arthritis (RA) in a large US observational cohort.

METHODS

Semiannual patient-reported data in the ARAMIS (Arthritis, Rheumatism and Aging Medical Information System) data bank from January 1998 to January 2006 were analyzed retrospectively using pooled logistic regression (with adjustment for center-level and temporal effects) to identify patient-, disease-, and treatment-related characteristics associated with the initiation of biologics for the treatment of RA.

RESULTS

The analysis included 1545 patients from 7 US centers. By 2006, 41.4% of 679 patients remaining in the sample had received biologics. Initiation of biologics was significantly associated with greater disability in the previous 6-month period (per 1-unit increase in Health Assessment Questionnaire score: odds ratio [OR] = 1.45; 95% CI, 1.22-1.72; P < 0.01) and treatment in the previous period with steroids (OR = 2.24; 95% CI, 1.76-2.85; P < 0.01) or nonbiologic disease-modifying antirheumatic drugs (OR = 2.43; 95% CI, 1.71-3.46; P < 0.01). Two sociodemographic factors were significant predictors of decreased use of biologics: older age (per 10 years: OR = 0.74; 95% CI, 0.660.82; P < 0.01) and lower annual income (per $10,000 reduction: OR = 0.95; 95% CI, 0.91-1.00; P = 0.04). There were no significant differences with respect to sex, race, employment status, comorbidity, previous NSAID use, or treatment center.

CONCLUSIONS

Disease- and treatment-related factors were significant predictors of the initiation of biologics for RA. Independent of these factors, however, biologics were less often used in patients who were older and those with lower incomes. Use of biologics increased steadily over the period studied.

Health economic issues in rheumatoid arthritis

The objectives of treatment in rheumatoid arthritis (RA) are to reduce temporary symptoms due to inflammatory activity and, more importantly, to preserve function. The introduction of potent disease-modifying anti-rheumatic drugs (DMARDs) in recent years has increased the opportunities for effective treatment. However, these treatments come at a substantially higher cost than traditional DMARDs and therefore compete with other essential interventions for limited resources. They have triggered a debate on whether they represent an efficient use of resources, which patients should be treated, when, and for how long. Cost-effectiveness analysis attempts to estimate the trade-offs involved in these decisions and to provide information that can help in making them. However, in chronic progressive diseases, health gains and any potential associated economic benefits are often most evident in the long-term. As a consequence, the impact of new treatments has to be estimated using models that can project available knowledge, such as results from clinical trials or short-term follow-up studies in clinical practice, into the future. These models also allow scenarios to be explored that provide the best value for money, for example by defining subgroups for which treatment is most effective, or criteria that define when treatment should be stopped. Economic evaluation in RA has a long tradition, with the first study performed about 20 years ago. However, with the recent drug introductions, the field has witnessed an explosion of economic studies. Modelling techniques have become more sophisticated to overcome concerns about their validity. At the same time, they may appear less transparent, making it difficult for non-specialists to understand the details. This article, rather than reviewing all published models and comparing them, attempts to illustrate the inputs required for such studies, and the influence that different approaches and datasets can have on the results.

Is it possible to identify early predictors of the future cost of chronic arthritis? The VErA project

This study was conducted to identify early predictors of the total cost of inflammatory arthritis (IA). One hundred and eighty patients affected by undifferentiated arthritis (UA) or rheumatoid arthritis (RA) were included in the French Very Early rheumatoid Arthritis (VErA) cohort between 1998 and 2001. Health economic data for 2003 were collected using a patient self-questionnaire. Results were analysed in terms of direct, indirect and total costs in 2003 euros (2003euro) for the population as a whole and in diagnostic subgroups. A payor perspective (the French National Health Insurance, in this case) was adopted. Multiple linear regression models were used to identify predictors of total cost from among the criteria assessed on recruitment. Results of the study showed that for the study population as a whole, the mean total cost was euro4700 per patient. The costs attributable to the RA and UA sub-groups were euro5928 and euro2424 per patient, respectively. In a univariate analysis, certain parameters were significantly correlated with a higher cost of illness. In the multivariate analysis, some of these parameters were further identified as being predictive of higher cost. Two strong significant, early predictors of total cost were identified: higher pain (P = 0.002) and the presence of rheumatoid factor (P = 0.004). In the RA sub-group, lower grip strength of the dominant hand (P = 0.039) was another predictor of the illness's subsequent economic impact. In conclusion, our data show that simple clinical and laboratory parameters can be used early in the course of IA to predict the condition's impact on healthcare budgets.

Outcome measures in rheumatologic clinical trials and systemic sclerosis

OMERACT (Outcome Measures in Rheumatologic Clinical Trials) is a loose organization of rheumatologists, epidemiologists and statisticians whose aim is to improve measurements in the rheumatic diseases. In this context, some SSc measures of response have been found to be valid: the modified Rodnan skin score, the Raynaud's condition score, the forced vital capacity as part of pulmonary function tests, right heart catheterization haemodynamics, serum creatinine, blood pressure and complete blood counts in scleroderma renal crisis and serum creatine phosphokinase as a measure of muscle disease in SSc. Other measures are being tested and have nearly been validated, including the gastrointestinal questionnaire in SSc. Finally, some measures have been found wanting or are not fully tested--in this case for pulmonary arterial hypertension, where effort is presently being focused. These include the echocardiogram, high-resolution CT scan of the lungs, pulmonary function tests, 6-min walking test and MRI.

Can we derive an 'exchange rate' between descriptive and preference-based outcome measures for stroke? Results from the transfer to utility (TTU) technique

Background

Stroke-specific outcome measures and descriptive measures of health-related quality of life (HRQoL) are unsuitable for informing decision-makers of the broader consequences of increasing or decreasing funding for stroke interventions. The quality-adjusted life year (QALY) provides a common metric for comparing interventions over multiple dimensions of HRQoL and mortality differentials. There are, however, many circumstances when – because of timing, lack of foresight or cost considerations – only stroke-specific or descriptive measures of health status are available and some indirect means of obtaining QALY-weights becomes necessary. In such circumstances, the use of regression-based transformations or mappings can circumvent the failure to elicit QALY-weights by allowing predicted weights to proxy for observed weights. This regression-based approach has been dubbed 'Transfer to Utility' (TTU) regression. The purpose of the present study is to demonstrate the feasibility and value of TTU regression in stroke by deriving transformations or mappings from stroke-specific and generic but descriptive measures of health status to a generic preference-based measure of HRQoL in a sample of Australians with a diagnosis of acute stroke. Findings will quantify the additional error associated with the use of condition-specific to generic transformations in stroke.

Methods

We used TTU regression to derive empirical transformations from three commonly used descriptive measures of health status for stroke (NIHSS, Barthel and SF-36) to a preference-based measure (AQoL) suitable for attaching QALY-weights to stroke disease states; based on 2570 observations drawn from a sample of 859 patients with stroke.

Results

Transformations from the SF-36 to the AQoL explained up to 71.5% of variation in observed AQoL scores. Differences between mean predicted and mean observed AQoL scores from the 'severity-specific' item- and subscale-based SF-36 algorithms and from the 'moderate to severe' index- and item-based Barthel algorithm were neither clinically nor statistically significant when 'low severity' SF-36 transformations were used to predict AQoL scores for patients in the NIHSS = 0 and NIHSS = 1–5 subgroups and when 'moderate to severe severity' transformations were used to predict AQoL scores for patients in the NIHSS ≥ 6 subgroup. In contrast, the difference between mean predicted and mean observed AQoL scores from the NIHSS algorithms and from the 'low severity' Barthel algorithms reached levels that could mask minimally important differences on the AQoL scale.

Conclusion

While our NIHSS to AQoL transformations proved unsuitable for most applications, our findings demonstrate that stroke-relevant outcome measures such as the SF-36 and Barthel Index can be adequately transformed to preference-based measures for the purposes of economic evaluation.

Poor reporting of search strategy and conflict of interest in over 250 narrative and systematic reviews of two biologic agents in arthritis: a systematic review

OBJECTIVE

To evaluate the quality of reviews about etanercept (ETN) and infliximab (IFX), two biologic treatments for rheumatoid arthritis (RA).

STUDY DESIGN

A comprehensive, systematic review, including searches of MEDLINE, EMBASE, and other electronic databases and hand-searches for published and unpublished literature. Two raters independently examined each article and identified systematic reviews as those including either a description of: (1) sources for identification and data retrieval; or (2) search strategy. They applied the quality of reporting of meta-analyses (QUOROM) instrument to systematic reviews.

RESULTS

Of 3,620 total citations, 281 were identified as reviews. Of these, 26 (9%) qualified as systematic rather than narrative. Overall, few reviews described selection of sources, critical appraisal, or quantitative summary or synthesis. Systematic reviews most often failed to explain validity assessment. Several articles did not disclose authors' participation in industry-funded clinical trials. Most reviews published in high impact factor and rheumatology journals did not meet many quality standards. Significant associations existed between review type (narrative vs. systematic) and reported funding (P=0.05), conflicts of interest (P=0.005), and country of publication (P<0.0001).

CONCLUSION

More than 90% of the published reviews were narrative and did not report methods and conflicts of interest in sufficient detail, raising concerns about selection and reporting bias.

Impact of disease progression on health status, quality of life and costs in rheumatoid arthritis in Hungary

A rheumatoid arthritis (RA) krónikus, progresszív, szimmetrikus sokízületi gyulladás. A betegek hosszú távú gondozásához és a költséghatékonysági modellekhez alapvető ismerni és standardizáltan mérni a betegség lefolyását és annak következményeit. Célkitűzés: A betegségprogresszió és az egészségi állapot, életminőség és költségek kapcsolatainak vizsgálata magyarországi RA-s betegeken. Módszer: 2004. április–augusztus között keresztmetszeti kérdőíves vizsgálatot végeztek RA-s betegek bevonásával hat fekvőbeteg-osztályos háttérrel rendelkező járóbeteg-szakambulancián. Standardizált kérdőívekkel vizsgálták a betegség progresszióját kifejező funkcionális állapotot (HAQ), az egészségi állapotot (EQ-5D), a betegségspecifikus életminőséget (RAQoL), felmérték a betegségaktivitást (DAS) és a betegséggel összefüggő költségeket, elemezték e paraméterek kapcsolatát. Eredmények: 255 beteg adatait elemezték [átlagos életkor: 55,5 ± 12,3 év; a betegség fennállása: 9,0 ± 9,3 év; HAQ: 1,38 ± 0,76; EQ-5D: 0,46 ± 0,33; RAQoL: 16,2 ± 8,1; DAS: 5,09 ± 1,42; költség: 1 043 163 (± 844 750) Ft/beteg/év]. Szignifikáns korrelációt találtak az összes esetben ( p < 0,01), függvénykapcsolat volt kimutatható: EQ-5D index = 1,014–0,25 × HAQ–0,041 × DAS és HAQ = 0,314 + 0,065 × RAQoL. Betegségsúlyossági csoportonként (0,5 HAQ-léptékkel) vizsgálva, az egészségi állapot átlaga rosszabbodott (EQ-5D: 0,784; 0,576; 0,504; 0,367; 0,211; 0,022), és az átlagos költség emelkedett (628 280; 888 187; 953 759; 1 291 218; 1 346 112; 1 371 674 Ft/beteg/év) a betegség előrehaladásával. Minimális klinikailag szignifikáns funkciócsökkenés (0,25 HAQ-változás) 0,0705 EQ-5D-csökkenésnek és 1,884 RAQoL-emelkedésnek felelt meg, nem súlyosan aktív (DAS < 5,1) esetekben kisebb a változás (EQ-5D: 0,05725). Következtetések: A betegségprogresszió és az általános egészségi állapot, életminőség és a költségek kapcsolata nem tér el jelentősen a nemzetközi eredményektől. A betegségköltségek nagysága azonban jelentősen kisebb Magyarországon, mint a fejlett országokban. A vizsgálat adatokkal szolgál a hazai egészség-gazdaságtani elemzésekhez.

The burden of rheumatoid arthritis and access to treatment: outcome and cost-utility of treatments

Within the series of articles investigating the burden of rheumatoid arthritis (RA), this paper reviews the methods used for economic assessment of the RA treatments by HTA agencies and other bodies involved in cost-effectiveness analysis and the current status of the field. The overall methods, as well as the challenges, of cost-effectiveness analysis in RA are common to all chronic progressive diseases where much of the treatment benefit is delayed, while costs occur immediately. Also, as in all disabling diseases, much of the costs occur outside the health-care system, due to the rapid loss of work capacity and the need for informal care in the later stages of the disease. Thus, it is essential to adopt a long-term view and consider costs from the perspective of society, rather than the health-care service, to increase the relevance of the results for policy making.

Quality-of-life assessment in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic and lifelong autoimmune disorder that results in significant pain, disability and excess mortality if untreated or inadequately treated. Quality-of-life (QOL) assessments are particularly important in the absence of a cure for RA. Generic and disease-specific patient-reported QOL instruments, such as the Health Assessment Questionnaire (HAQ) Disability Index and the SF-36, have proven validity and sensitivity for assessment of changes in QOL in clinical trials of disease-modifying anti-rheumatic drugs (DMARDs). However, these instruments are rarely utilized in clinical practice, and patients have reported that the actual clinical assessments alone do not address important parameters, such as fatigue and disturbed sleep, which significantly affect QOL.New biological DMARDs have shown significant efficacy in improving clinical and QOL parameters in randomized controlled trials. However, the high cost of biological DMARDs compared with non-biological DMARDs is a factor in the increasing health costs associated with the treatment of RA. Generic health utility instruments that measure QOL parameters enable calculation of the increased QALYs associated with more costly treatment in patients with RA. The costs per QALY associated with biological DMARDs in RA appear to be comparable to those of other accepted medical interventions. Interest in incorporating QOL parameters in formulary and public health decision making concerning the use of new agents for RA is increasing.

Economic evaluations in rheumatoid arthritis: a critical review of measures used to define health States

We reviewed the clinical measures used in rheumatoid arthritis (RA) economic evaluations with respect to their relevance and sensitivity to changes in survival, health-related quality of life (HR-QOL) and costs. We compared the measures from the economic perspective and discussed the validity of methods used to extrapolate beyond the trial data. Cost-effectiveness evaluations of disease-modifying antirheumatic drugs in RA were identified by searching MEDLINE, EMBASE, Econlit and NHS EED databases. Studies were retained if they extrapolated beyond randomized controlled trial evidence using relationships between clinical measures, costs and utilities. In the 22 studies identified, clinical severity was measured using the Health Assessment Questionnaire (HAQ) Disability Index, the American College of Rheumatology (ACR) response criteria, the Disease Activity Score (DAS) or a combination of the HAQ and DAS. The HAQ is correlated with mortality, costs and HR-QOL instruments, and several studies used linear relationships to model these associations. However, a polynomial relationship or discrete states may be more appropriate for patients at the extremes of the disease spectrum, and numerous HAQ health states may be required to capture differences in mortality risk. While the ACR response criteria is a more comprehensive measure than the HAQ, it is a relative measure, which creates difficulties when estimating absolute changes in HR-QOL, costs and mortality risk. The evidence base linking DAS scores with HR-QOL instruments, costs and mortality is less robust, possibly due to the comparatively recent development of the measure and the limited number of possible scores (mild/moderate/severe). While there is some evidence of a relationship between DAS scores and costs, the DAS does not capture all aspects of HR-QOL, and no significant relationship has been established with mortality risk. Evidence suggests the HAQ to be the primary clinical measure for use in economic evaluations as it is measured in almost all clinical studies, and is closely correlated to health utilities, mortality and costs. While new developments suggest the sensitivity of health states may be improved by combining the HAQ with measures such as the DAS, further research is required in this area. Further research is also required to explore the advantages in using either continuous or discrete health states.

Thoughts on health economics in rheumatoid arthritis

In this manuscript we discuss the reasons why and how health economics is important, the type of economic studies that are relevant in healthcare to different stakeholders in general, and what analyses can and have been performed in the field of rheumatoid arthritis (RA). We will thus specifically address costs and outcome measurements in RA, as well as the need for modelling in chronic progressive diseases.

Rituximab in patients with rheumatoid arthritis: systematic review

A rheumatoid arthritis terápiájában legújabban alkalmazott gyógyszerek a biológiai szerek. Legutóbb a B-lymphocyta-gátló rituximabot törzskönyvezték rheumatoid arthritis indikációjában. A rituximabot eddig a non-Hodgkin-lymphoma kezelésében alkalmazták. Európai és a magyar reumatológusok ajánlása szerint a rituximab rheumatoid arthritisben azoknak a betegeknek javasolható, akiknél a kórtörténetben eredménytelenség vagy toxicitás miatt sikertelen TNF-α-gátló kezelés szerepel. Célkitűzés: A rituximabkezelés klinikai hatásosságáról rheumatoid arthritisben rendelkezésre álló szakirodalom áttekintése. A rituximabkezelés hatásosságának és biztonságának értékelése. Módszer: A szerzők a MEDLINE- és Cochrane-adatbázisokban megkeresték az összes randomizált, kontrollált rituximabvizsgálatot rheumatoid arthritisben. Elvégezték az adatok metaanalízisét. Eredmények: Az irodalomkeresés során 3 randomizált kontrollált klinikai vizsgálatot azonosítottak a szerzők, amelyekben összesen 1145 beteget követtek. A TNF-α-gátló kezelésre nem reagáló, súlyos gyulladásos tüneteket mutató betegeknél rituximabkezelés mellett 33%-kal több betegnek (95%; KI: 25–41%) javulnak a tünetei az American College of Rheumatology 20 kritérium szerint, mint ha nem kezelnék őket. Majdnem 5-ször nagyobb (relatív kockázat = 4,77; 95%; KI, 3,12–7,31) esélyük van a javulásra, mint kezelés nélkül. A funkcionális állapotot jelző Health Assessment Questionnaire pontszám is szignifikánsan nagyobb mértékben ( p < 0,001) javult a rituximabcsoportban (–0,4 pont), mint a kontrollcsoportban (–0,1 pont). Rituximabkezelés hatására a mérsékelt vagy jó választ adó betegek aránya 38%-kal nagyobb (95% KI, 32–44%) a rituximabkezelési ágon, mint a kontrollcsoportban, a különbség szignifikáns ( p < 0,00001). A rituximab a radiológiai progressziót is javítja a TNF-α-gátló kezelésre nem reagáló betegek között. Következtetések: A rituximab új, hatásos terápiás lehetőség a rheumatoid arthritis terápiájában. A TNF-α-gátló kezelésre nem reagáló vagy azt nem toleráló betegeknél is javulás érhető el.

Anti-rheumatic activities of histone deacetylase (HDAC) inhibitors in vivo in collagen-induced arthritis in rodents

BACKGROUND AND PURPOSE

Rheumatoid arthritis (RA) is a chronic inflammatory disease. Histone deacetylase inhibitors (HDACi), a new class of anti-cancer agents, have recently been reported to exhibit potent anti-inflammatory activities. A proof of concept study was carried out with suberoylanilide hydroxamic acid (SAHA) and MS-275, two HDACi currently undergoing clinical investigations for various oncological indications.

EXPERIMENTAL APPROACH

The anti-rheumatic effects of SAHA and MS-275 were assessed in both mouse and rat collagen induced arthritis (CIA) models.

KEY RESULTS

SAHA exhibited moderate prophylactic efficacy. It attenuated paw swelling due to inflammation, decreased bone erosion in both mice and rats and reduced slightly the RA-induced bone resorption in rats. However, SAHA could not inhibit the onset of arthritis. In contrast, MS-275 displayed dramatic anti-rheumatic activities. In prophylactic intervention, high doses of MS-275 prevented bone erosion and markedly delayed the onset of arthritis; at low doses, MS-275 strongly attenuated paw swelling, bone erosion, and bone resorption associated with RA. Furthermore, the therapeutic efficacy of MS-275 was also documented. After the onset of arthritis, it could stop the disease progression and joint destruction. An anti inflammatory effect of MS-275 was also confirmed through its capacity to decrease serum IL-6 and IL-1beta levels in the CIA induced mouse model. The anti-rheumatic activity of MS-275 was also confirmed through histological observation. No synovial hyperplasia, pannus formation, cartilage or bone destruction were observed in the high dose prophylactic intervention in mice.

CONCLUSION AND IMPLICATION

This study strongly supported HDACi as an innovative therapeutic strategy for RA.

What is after cytokine-blocking therapy, a novel therapeutic target--synovial Epstein-Barr virus for rheumatoid arthritis

There has been significant progress in cytokine-blocking therapy for treatment of rheumatoid arthritis (RA) However, inhibition of cytokines involved in immune defense raises severe side effects. The cost of cytokine-blocking treatment is another major issue. Why are levels of inflammatory cytokines increased in RA patients? We have a large amount of circumstantial and direct evidence for the presence of Epstein-Barr virus (EBV) in RA synovial cells. Here, we provide an overview of the implications for novel approaches to therapy for RA patients, based on the most recent available evidences of anti-viral agents.

Use of biologics in rheumatoid arthritis: Where are we going?

PURPOSE

The pharmacology, efficacy, safety, and costs of biologic agents that are approved by the Food and Drug Administration or are under review for the management of rheumatoid arthritis (RA) are discussed. Biologic therapies that are currently under investigation in early- and late-phase clinical trials are summarized at the end of this report.

SUMMARY

The use of biologic agents for the treatment of RA has significantly improved the management of this disease. Experimental and clinical studies have shown that these agents ameliorate the signs and symptoms of RA, slow radiographic progression of disease, and improve physical function and quality of life. Data also support that early initiation of therapy with these agents improves long-term outcomes. However, biologic agents are associated with adverse effects that health care providers need to recognize and manage.

CONCLUSION

Biologic agents have revolutionized the treatment of RA by reducing the signs and symptoms of RA, slowing radiographic progression of joint destruction, and improving physical function and quality of life in affected patients.

Alternative Decision Analysis Modeling in the Economic Evaluation of Tumor Necrosis Factor Inhibitors for Rheumatoid Arthritis

OBJECTIVES

To provide a review of the studies that use decision models in the economic evaluation of tumor necrosis factor (TNF) inhibitors in rheumatoid arthritis (RA) and to address some important issues surrounding the choice of such modeling techniques in these economic evaluations.

METHODS

A systematic literature search was conducted by 1 author from the literature published from January 1996 to March 2005 through Medline, Embase, and Cochrane library databases.

RESULTS

The review yielded 29 studies that used decision models. Only 10 studies used a decision model in the economic analysis of the TNF inhibitors and were included in the final review. Decision model types included the following in the review articles: decision tree (2), Markov model (7), and discrete event simulation (1). These models vary in complexity and their choice depends on the course of disease, the impact of treatment, and the available data.

CONCLUSIONS

Based on the results derived from alternative modeling techniques, it is safe to say that all methods can provide useful information with regard to economic evaluations of TNF inhibitors. Even though different modeling techniques provide an appropriate representation of available data, their results should be interpreted contingent on the input data, assumptions, sensitivity analyses, and other alternative scenario analyses.

RELEVANCE

The transparency in the models will encourage end users such as policymakers and prescribers to make informed judgments regarding the appropriateness of the methods and the validity of the results.

TNFα blockers do not improve the hearing recovery obtained with glucocorticoid therapy in an autoimmune experimental labyrinthitis

The effectiveness of etanercept [tumour necrosis factor-alpha (TNFalpha) blocker] and corticoids in treating immuno-mediated inner ear disease (IMIED) was compared in an animal model of autoimmune labyrinthitis. IMIED is one of the few forms of sensorineural hearing loss that is reversible with proper medical treatment. While the effectiveness and usefulness of immunomodulating agents (corticosteroids) in treating IMIED have been demonstrated, TNFalpha antagonists, which inhibit granuloma formation in rheumatoid arthritis and other autoimmune diseases, have been considered as an alternative therapy. The efficacy of etanercept (anti-TNFalpha) was evaluated in a guinea pig model of experimental autoimmune labyrinthitis in which 25 guinea pigs were divided in a control group, which was used to document the rise in hearing thresholds following immunisation, and two experimental groups, which were treated with steroids (6-methylprednisolone) and anti-TNFalpha (etanercept), respectively, after the immunisation. Comparison of the auditory thresholds obtained by means of auditory brainstem response (ABR) revealed that the auditory thresholds of the two experimental groups were not statistically different (6-methylprednisolone: 41.5 dB, SD: 8.51; etanercept: 37.5 dB, SD: 7.91) and that both compared favourably with that of the control group (60 dB, SD: 7.91) at p=0.001. We therefore conclude that etanercept is as effective as glucocorticoids in an animal model of autoimmune labyrinthitis; however, the potential adverse effects and high price of the former advise against its use as an initial therapy for IMIED.

Adalimumab

Adalimumab (Humira) is a recombinant, fully human anti-tumor necrosis factor (TNF) monoclonal antibody approved in the US and Europe for the treatment of adult patients with moderate to severe, active rheumatoid arthritis (RA). In combination with methotrexate or standard antirheumatic therapy or as monotherapy, adalimumab effectively reduced signs and symptoms of RA, induced remission, improved physical function and inhibited the progression of structural damage in several randomized, double-blind, placebo-controlled phase III trials. The drug was generally well tolerated, with most adverse events being mild to moderate, and the serious adverse events profile being similar to that generally seen in patients with RA not receiving anti-TNF agents. Adalimumab was at least as cost effective as other anti-TNF agents used in the therapy of RA, and provided significant improvements in patients' health-related quality of life. Overall, adalimumab in combination with methotrexate or standard antirheumatic therapy is valuable as a first-line therapeutic option in patients with early, aggressive RA, and a second-line therapeutic option in patients with long-standing, moderate to severe RA. For the latter indication, adalimumab may also be used as monotherapy.

Cost effectiveness of tumour necrosis factor-alpha inhibitors as first-line agents in rheumatoid arthritis

BACKGROUND AND OBJECTIVE

Rheumatoid arthritis (RA) is an autoimmune disease with an unknown aetiology that results in >9 million physician visits and >250 000 hospitalisations per year in the US. Tumour necrosis factor-alpha (TNFalpha) inhibitors are effective agents in treating RA; however, their cost effectiveness as first-line agents has not been investigated. This study aimed to examine the cost effectiveness of using TNFalpha inhibitors (both as monotherapy and in combination with methotrexate) as first-line agents versus methotrexate (monotherapy) from a payer perspective.

METHODS

A Markov model was developed utilising a discount rate of 3% per annum, a cycle length of 1 year and a lifetime time-horizon for a hypothetical cohort of US females aged 55-60 years who had been diagnosed with RA. The source of data for predicted probabilities, expected mortality rates and treatment costs in year 2005 US dollars (drug, toxicity, monitoring and hospitalisation) was from the literature. These costs are assigned in 5-year cycles (calculated from initial 1-year estimates) along with the effect on quality-adjusted life-years (QALYs), which were calculated using the Health Assessment Questionnaire score. Univariate sensitivity analyses were conducted on all relevant parameters.

RESULTS

Adalimumab, etanercept, adalimumab plus methotrexate and infliximab plus methotrexate had incremental cost-effectiveness ratios (ICERs) versus methotrexate monotherapy of $US63 769, $US89 772, $US194 589 and $US409 523 per QALY, respectively. When taking into consideration age at diagnosis, the ICER for etanercept ranged from $US84 129 to $US96 225 per QALY. In considering males for the base-case age at diagnosis, the ICER for etanercept versus methotrexate was $US85 100 per QALY. The average lifetime cost across all treatment arms in a woman diagnosed between 55 and 60 years of age was $US211 702.

CONCLUSION

While these ICERs cannot be used to directly compare one biological agent with another since there are no comparative trials, they do provide a valid comparison versus methotrexate as first-line agents. Depending where the cost-effectiveness threshold is drawn (i.e. whether it is considered to be $US50 000 or $US100 000 per QALY), etanercept and adalimumab may be considered relatively cost-effective first-line treatments for RA compared with methotrexate monotherapy.