First-Line Biologic Therapy Not Cost-Effective in Rheumatoid Arthritis Patients

Initiating biologics before triple therapy increases costs and provides minimal incremental benefit.

It is more cost-effective for patients with rheumatoid arthritis (RA) to switch from a disease-modifying antirheumatic drug (DMARD) to a triple therapy strategy first, before switching to a biologic, a new study suggests.

RA patients typically begin treatment with conventional DMARDs. If symptoms persist, current guidelines from the American College of Rheumatology recommend adding a biologic drug.

However, recent findings from the RACAT clinical trial question the cost-effectiveness of this approach. The results found that triple therapy—–a combination of sulfasalazine, hydroxychloroquine, and methotrexate––is equally as effective as switching directly to a biologic.

In a study published in Annals of Internal Medicine, the investigators sought to determine the cost-effectiveness of etanercept-methotrexate compared with triple therapy as a first-line strategy.

They conducted a within-trial analysis based on 353 participants in the RACAT trial, and a lifetime analysis that extrapolated costs and outcomes using a decision analytic cohort model. The patients continued to have uncontrolled symptoms of RA after at least 12 weeks of methotrexate therapy.

Incremental costs, quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were measured at 24 months and lifetime.

In the within-trial analysis, the results of the study showed that etanercept-methotrexate as first-line therapy provided marginally more QALYs, but accumulated substantially higher drug costs. Differences in other costs between strategies were negligible, the authors noted.

The ICERs for first-line etanercept-methotrexate were $2.7 million per QALY and $0.98 million per QALY over 24 and 48 weeks, respectively.

Findings from the lifetime analysis suggest that first-line biologic treatment would result in 0.15 additional lifetime QALYs, but would cost an incremental $77,290, leading to an ICER of $521,520 per QALY per patient.

“Initiating biologic therapy without trying triple therapy first increases costs while providing minimal incremental benefit,” the authors concluded.