Session Type: Abstract Submissions (ACR)
Background/Purpose: The 2012 German rheumatoid arthritis (RA) treatment guidelines recommend sequential use of disease-modifying antirheumatic drugs (DMARDs) in a treat-to-target (T2T) framework. Biologics are recommended for patients not responding to two conventional DMARDs or with high disease activity and indicators for poor prognosis while on initial DMARD therapy. The objective of this study was to assess the cost-effectiveness of three T2T strategies for achieving and maintaining remission among early RA patients in Germany.
Methods: A Markov model was developed to evaluate the costs and outcomes of three T2T strategies (A, B, C) among early RA patients over a 20-year time horizon from a German societal perspective. Four health states (i.e., remission and low, moderate, and severe disease activity) were defined based on the Disease Activity Score 28 joints (DAS28). At the beginning of each cycle (every 6 months), patients not achieving remission switched to the next treatment. The treatment strategies are: (A) first-line adalimumab (ADA) + methotrexate (MTX); (B) first-line MTX monotherapy, followed by a hybrid approach with ADA + MTX for patients with high disease activity and one DMARD + MTX for patients with low or moderate disease activity after MTX failure; and (C) (current recommended treatment sequence): ADA + MTX after 2 conventional DMARDs. Transition probabilities were estimated using efficacy data from randomized controlled trials. Both direct medical costs (i.e., drug and administration, monitoring, medical, and adverse event costs) and indirect costs (productivity loss) were considered; costs inputs were derived from public data or literature based on the 2012 German treatment guidelines. Utility inputs were estimated based on the OPTIMA trial. Incremental cost-effectiveness ratios (ICERs) comparing Arm A or B vs. C were computed as incremental costs per quality-adjusted life year (QALY) gained. Univariate sensitivity analyses were performed.
Results: At 20 years, Arm A led to an additional 7.8% of patients in remission and 0.280 additional QALY gained compared to Arm C; while Arm B vs. C yielded an additional 0.5% of patients in remission and 0.027 QALY gained. The incremental costs for Arms A and B vs. C over 20 years were €12,135 and €989, respectively, resulting in ICERs of €43,404 per QALY gained for Arm A vs. C and €37,206 for Arm B vs. C as well as ICERs of €9,003 per additional year in remission for Arm A vs. C and €10,609 for Arm B vs. C. Results were robust in univariate sensitivity analyses. Most scenarios (86% for A vs. C and 99% for B vs. C) yielded an ICER below an assumed willingness-to-pay threshold of €50,000 per QALY with exceptions of excluding indirect costs for both comparisons and a shorter time horizon for Arm A vs. C.
Conclusion: In a T2T framework in early RA, strategies starting with ADA + MTX and starting with MTX monotherapy followed by early switching to ADA + MTX for patients with high DAS28 were cost-effective compared with the current recommended treatment sequence with ADA + MTX use after two conventional DMARDs.
Z. Y. Zhou,
J. W. Shaw,
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ACR Meeting Abstracts - https://acrabstracts.org/abstract/cost-effectiveness-of-different-treatment-sequences-including-adalimumab-in-the-treat-to-target-framework-for-early-rheumatoid-arthritis-in-germany/