Background/Purpose: Psoriatic arthritis (PsA) is an inflammatory condition characterized by peripheral arthritis and psoriatic skin lesions requiring therapies that control both skin and joint symptoms. In the absence of head-to-head trials, indirect comparison provides informative evidence for decision makers. This study compared the clinical (ACR 20/50/70; PASI 75/90) and cost-effectiveness outcomes of targeted immunomodulators (TIMs) among PsA patients without prior biologic treatment via a network meta-analysis (NMA).

Methods: A systematic literature review was conducted to identify Phase 3 randomized controlled trials (RCTs) for tumor necrosis factor-α inhibitors (TNFi’s: adalimumab [ADA], certolizumab pegol [CZP], etanercept [ETN], golimumab [GOL], and infliximab [INF]), an interleukin-17A inhibitor (secukinumab [SEC]), an interleukin-12/23 inhibitor (ustekinumab [UST]), and a phosphodiesterase-4 inhibitor (apremilast [APR]) in active PsA. Joint (ACR 20/50/70) and skin (PASI 75/90) responses at Week 24 were estimated via Bayesian NMA among biologic-naïve patients. Treatment costs were based on Wholesale Acquisition Cost as of May 8, 2017 and included drug acquisition and administration costs. Incremental costs per responder relative to placebo were calculated as incremental treatment costs during 24 weeks divided by response rate difference vs. placebo.

Results: Eleven RCTs that reported ACR and/or PASI responses at Week 24 among biologic-naïve PsA patients were included. GOL, ADA, and SEC 150 had higher ACR 20 response than other TIMs. In terms of ACR 50, INF, ETN, and ADA had higher efficacy compared with other TIMs (Table 1). With respect to ACR 70 and PASI responses, ADA, INF, and GOL had higher efficacy than other TIMs. In terms of cost-effectiveness, INF ($50,812 for ACR 50/$35,227 for PASI 75), ADA ($78,608/$41,093), and GOL ($80,533/$37,443) were associated with lower incremental costs per additional ACR 50 responder and per additional PASI 75 responder than other TIMs (Figure 1A). A similar ranking of these drugs was observed in ICPR for ACR 70 and PASI 90 (Figure 1B).

Conclusion: At Week 24, INF, GOL, and ADA had the lowest incremental cost per responder for joint and skin outcomes in PsA patients without prior biologic treatments.

Figure 1. Incremental cost per responder over 24 weeks (ACR 50 vs. PASI 75 and ACR 70 vs. PASI 90)¹

[1] ICPR for ACR 50 and ACR 70 in CZP were $173,601 and $201,998. ICPR for ACR 50 and ACR 70 in APR were $250,338 and $4,659,629.
PASI responses were not reported for CZP and APR in the biologic-naïve population.