SAN DIEGO – In patients with early rheumatoid arthritis, treatment with a combination of disease-modifying antirheumatic drugs is more cost effective than an immediate or step-up approach using etanercept and methotrexate, a new analysis demonstrated.
"The benefits from all strategies were comparable, but biologics strategies were almost twice as expensive [as] triple strategies, producing incremental cost-effectiveness ratios higher than what most health care settings would find acceptable," Kaleb Michaud, Ph.D., said at the annual meeting of the American College of Rheumatology.
Dr. Kaleb Michaud
Dr. Michaud of the division of rheumatology and immunology at the University of Nebraska Medical Center, Omaha, and his associates analyzed data from 755 patients enrolled in the randomized, 2-year TEAR (Treatment of Early Aggressive RA) trial (Arthritis Rheum. 2012;64:2824-35), which compared the long-term effectiveness of using a triple therapy approach for treating RA with a strategy of using a etanercept (Enbrel) plus methotrexate. They studied four approaches: immediate triple therapy of methotrexate, sulfasalazine, and hydroxychloroquine; immediate treatment with etanercept and methotrexate; a step-up triple therapy; and a step-up etanercept therapy. The researchers incorporated estimates of annual discontinuation rates of triple therapy and etanercept of 22% and 10%, respectively, based on data from the National Data Bank for Rheumatic Diseases.
The analysis was limited to patients with RA duration of less than 3 years and those with active disease, defined as having four or more swollen joints with seropositivity and/or erosions. The mean disease duration was 3.6 months and the mean Disease Activity Score was 5.8. The researchers used a societal perspective and a Markov cohort model with 3% discounting to estimate quality-adjusted life year (QALY) measurements and the costs associated with therapy approaches in the TEAR trial.
Dr. Michaud, who is also codirector of the National Data Bank for Rheumatic Diseases, reported that the lifetime benefit of all four treatment approaches were comparable, within 0.06 QALYs of each other. However, the therapies that included etanercept were nearly twice as expensive because of the higher cost of the TNF inhibitor. Specifically, the costs were $152,400 in the immediate triple therapy group and $154,900 in the step-up triple therapy group, compared with $269,500 in the step-up etanercept group and $338,100 in the immediate etanercept group. The researchers determined that the lifetime incremental cost-effectiveness ratio of immediate etanercept to immediate triple therapy was $837,100/QALY.
"The immediate triple therapy dominated other arms at 1 and 2 years in this trial, and its results were most sensitive to the costs of etanercept and the reduction in triple therapy discontinuation rates," Dr. Michaud commented. "Our sensitivity analysis did not change our conclusions."
Dr. Michaud disclosed that the study was supported in part by a 2012 investigator award from the Rheumatology Research Foundation.