The clinical effectiveness agency for England and Wales said it plans to formally recommend three tumor necrosis factor inhibitors – etanercept, infliximab, and adalimumab – interchangeably for the treatment of psoriatic arthritis, saying the evidence suggests that they are equally safe and work equally well.
Current National Institute for Health and Clinical Excellence guidance mandates that infliximab be prescribed only in the event that etanercept or adalimumab (the two less expensive drugs) were contraindicated.
In draft guidance published June 11, NICE reviewers proposed that all three drugs be made available according to which is cheapest in a particular treatment setting.
People with active and progressive psoriatic arthritis who have peripheral arthritis with three or more tender joints, three or more swollen joints, and no response to at least two standard disease-modifying antirheumatic drugs (usually methotrexate and sulfasalazine, alone or in combination) are eligible for the treatments.
After examining data from randomized, controlled trials, the NICE reviewers determined that infliximab was associated with the highest probability of achieving a response for both the skin and joint symptoms in people with psoriatic arthritis.
The probability of response in joint disease was higher with etanercept than with adalimumab, they noted, and the probability of response in skin disease was higher with adalimumab than with etanercept. However, they urged that price be the sole determinant of TNF-inhibitor choice in each clinical setting.
Etanercept and adalimumab carry a similar price tag of about £9,300 each for the first treatment year, compared with £10,910 for infliximab. However, the NICE reviewers noted, “vial sharing arrangements for infliximab are available in some clinical settings and may reduce drug wastage by up to 50%,” and may make infliximab the cost-effective choice.
With any of the three drugs, NICE said, treatment should be terminated after 12 weeks if there is no adequate joint response, according to established criteria for psoriatic arthritis, although a dermatologist may find continuing treatment to be appropriate on the basis of skin response.
Final guidance on etanercept, infliximab, and adalimumab is expected in July, the agency said.