Background/Purpose: Refractory rheumatoid arthritis (RA) affects 30–40% of patients with limited therapeutic options and high disability burdens. Although CAR‑T therapy has been transformative in oncology and lupus, its prohibitive cost ( >$500K per patient) and limited accessibility in low- and middle-income countries (LMICs) constrain its application in RA. This systematic review evaluates CAR‑T’s cost‑effectiveness, global equity challenges, and proposes actionable strategies for sustainable integration into rheumatology practice, aligning with ACR Convergence 2025’s focus on healthcare delivery innovation.

Methods: Following PRISMA guidelines, we systematically reviewed 418 studies from PubMed and Embase (2000–2024) on CAR‑T costs, access, or policy in RA/autoimmunity. Two reviewers independently screened studies using predefined inclusion/exclusion criteria. Thematic analysis categorized findings into cost‑effectiveness, LMIC access barriers, and health system solutions, while study quality was assessed using AMSTAR‑2.

Results: Eighteen studies met inclusion criteria (12 preclinical, 6 clinical). In preclinical models, CD19 CAR‑T cells resolved synovitis in 80% of RA mice (p< 0.001 vs. controls), correlating with a 90% reduction in B cells and a 3‑fold increase in regulatory T cells (p=0.002). Early clinical trials reported 40–60% ACR50 response rates; however, 50% of patients experienced grade 1–2 cytokine release syndrome, which resolved with tocilizumab. CAR‑T costs ($750K/QALY) exceed WHO-recommended thresholds (150K/QALY), with < 5% of trials including LMIC sites, while tiered pricing models in pilot programs reduced costs by 60%.

Conclusion: CAR‑T therapy offers transformative potential for refractory RA but requires systemic reforms to address cost and equity challenges. Studies in oncology have demonstrated CAR‑T’s significant impact; adapting these cost-effectiveness models to RA supports the need for tiered pricing and LMIC-centric trials to ensure sustainable, equitable access. Implementing tiered pricing, initiating LMIC-centric trials, and developing engineered safety switches (e.g., ON/OFF CAR‑T) are recommended strategies to democratize access.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/car-t-therapy-in-rheumatoid-arthritis-a-health-systems-analysis-of-cost-and-global-equity/