Background/Purpose: Rising prevalence has led to increased demand for newer and potentially costly treatments for acute gouty arthritis, but few studies comparing effectiveness and costs of both older and novel treatments exist to guide best clinical practice. We aimed to assess the effectiveness and cost-effectiveness of currently available drug classes (non-selective and COX-2 selective non-steroidal anti-inflammatory drugs, colchicine, and systemic corticosteroids), as well as a long-acting biologic agent for the treatment of acute gout flare.

Methods: We modeled acute gout flare in 50 year old adult men with definite gout and no contraindications to considered therapies. Our decision analytic model incorporated quality of life impact of the flare, and costs and health effects of drugs and drug-related adverse events. The perspective was that of a third party payer, with an 8 week time horizon. Probabilities of response to therapies and adverse events, health state utilities, and costs in 2010 U.S. dollars were informed by published literature, U.S. hospital statistics, and payment algorithms that may be employed by a third party payer. We utilized published data for canakinumab (Ilaris®, Novartis) as representative of a long-acting biologic drug, although this drug is not approved for use in gout. Outcomes were measured in quality-adjusted-life-days (QALDs) and quality-adjusted-life-years (QALYs).

Results: Literature review revealed relatively small differences in overall effectiveness between treatments, in spite of a wide range of costs. Steroids provided 47.17 QALDs, colchicine 47.39 QALDs, and biologic 47.57 QALDs.  After accounting for toxicities and for the cost of COX-2 selective NSAIDs, both NSAID sub-classes were more expensive and less effective than other non-biologics. Intramuscular steroid cost $11,935 per QALY over no treatment, and branded colchicine cost $18,234 per QALY compared to steroid. The biologic drug cost over $22 million per QALY gained. Results were sensitive to untreated flare duration, probability of first-day drug response, and drug costs. When priced as an unbranded product, colchicine offered greater benefits at a lower cost than all other non-biologic drugs. A scenario analysis assuming equivalent efficacy of oral prednisone to intramuscular steroid showed prednisone to cost less than $3,000 per QALY, in which case branded colchicine exceeded a traditional willingness-to-pay threshold of $50,000 per QALY.

Conclusion: Compared to moderate dose intramuscular corticosteroid, colchicine provides reasonable value for money in the treatment of acute gout flare. When priced as an unbranded product, it is more effective and less expensive than all other options. If oral prednisone is similar in effectiveness to intramuscular steroid, then it is most cost-effective and branded colchicine costs much more for its incremental benefits. At current prices, biologic therapy does not provide additional benefits commensurate with its higher cost.

Limitations: These results apply only to uncomplicated gout among men in outpatient settings. Non-canakinumab biologics may have a different cost-effectiveness profile.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/cost-effectiveness-of-systemic-therapies-for-acute-gouty-arthritis/