Background/Purpose:
In Germany, Rheumatoid Arthritis (RA) can be treated with TNF-α inhibitors after the failure of conventional disease-modifying antirheumatic drugs like Methotrexate. The clinical use of TNF-α inhibitors grew from 2 % of treated RA patients in 2000 to 20 % in 2008. In 2012, Adalimumab was the most popular TNF-α inhibitor and the best selling drug in the German statutory health insurance system with net expenditure of € 581 mn. We aim to analyze the determinants of cost-effectiveness of Adalimumab and Methotrexate combination therapy for the treatment of RA in Germany.
Methods:
We set up an individual patient sampling lifetime model to simulate 10,000 hypothetical patients. Health benefits are recorded in terms of quality-adjusted life years (QALYs). Quality of life is derived from patients’ Health Assessment Questionnaire (HAQ) scores. Initially, patients can achieve one of three responses according to American College of Rheumatology (ACR) criteria or fail the therapy. Each ACR response is associated with an initial improvement in functional status. In each cycle, treatment might be discontinued due to loss of efficacy or adverse events. The patient is then switched to the next available treatment or palliative care. In the Adalimumab simulation arm, we add Adalimumab and Methotrexate combination therapy to the treatment algorithm after failure of both Methotrexate monotherapy and conventional triple therapy. Extensive sensitivity analysis investigates the effects of baseline age and functional status, cost and health effects discounting, methods for estimating quality of life and time horizon.
Results:
In the base case, patients gain 7.07 QALYs with conventional synthetic therapy and 9.92 QALYs if Adalimumab combination therapy is added to the treatment algorithm. The incremental cost-utility ratio (ICUR) is € 24,492 based on German list prices. If mandatory rebates and taxes are deducted for international comparison, the ICUR is only € 17,277. Adalimumab combination therapy lowers indirect costs from € 162,698 to € 134,363. From a societal perspective, the ICUR based on total costs is € 14,550 (€ 7,335 after deducting taxes and rebates). Sensitivity analyses shows that Adalimumab combination therapy becomes a dominant treatment option for younger baseline populations, i.e. Adalimumab is both more effective and less expensive for baseline age 30 due to savings in indirect costs. The biggest increase in ICURs can be seen if the simulation period is limited. If the maximum simulation period is limited to 10 years, ICURs double compared to a lifetime perspective.
Conclusion:
Cost-effectiveness of Adalimumab combination therapy in Germany compares favorably to analyses in other countries. Our lifetime simulation model shows that a sufficiently long simulation horizon is necessary to capture the complete range of possible outcomes and the associated longterm benefits of biological treatment. If a lifetime perspective is chosen, the most important determinant of cost-effectiveness is savings in indirect costs. Adalimumab combination therapy is most cost-effective for societies with high indirect costs like Germany.
Disclosure:
C. Gissel,
None;
G. Götz,
None;
H. Repp,
None;
U. Lange,
None.
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ACR Meeting Abstracts - https://acrabstracts.org/abstract/cost-effectiveness-of-adalimumab-for-rheumatoid-arthritis-in-germany/