Background/Purpose: Significant steps were done in creating new medications for treatment of rheumatoid arthritis (RA). As RA seriously affects the patients’ quality of life, the effectiveness of selected approaches is a primary concern for the National Health Insurance House (NHIH). Also being a chronic disease and having finite budgets it is important to find also the best results/costs approach. In case of first anti-TNF medication failure, options are prescribing a different anti-TNF or switching to Rituximab (RTX).

Our objective was to identify the best results/costs ratio by comparing two RA therapeutic alternatives: (1) switch to RTX after first anti-TNF failure versus (2) switching after 2-3 anti-TNF failure.

Methods: Based on data from NHIH, we analysed clinical results and the corresponding costs for N=400 RA patients, within a longitudinal (2002-2011), observational, population-based, cohort study. All patients had an anti-TNF medication as first treatment stage for 2.5 years (average). In the second stage, 208 patients (Group 1) were switched to RTX after first anti-TNF failure, and 192 (Group 2) had one or two more anti-TNF before switched to RTX. We evaluated the clinical effectiveness of the 2 approaches using: DAS28 and EULAR response. For efficiency assessment we calculated in each set-up indicators like: average spending to obtain the treatment target (LDA or remission), average cost per decreased DAS28 point and duration of treatment versus target.

Results: In Group 1, after the first 2 RTX cycles (12 months) medium ΔDAS28 was – 3.36 (compared to its value before the RTX switch). Group 2 evidenced first development of resistance to the anti-TNF medication, medium ΔDAS28 was +0.26 and after switch to RTX, ΔDAS28 decreased in 12 months with – 2.72. By September 1^st2011 (four RTX cycles), 91% of Group 1 patients experienced LDA (36.1%) and remission (54.9%) vs. 80.8% of the patients in Group 2 (40.4% LDA, 40.4% remission). While the groups are comparable in size, with respect to the total expenditure for N=400 patients, Group 1 represents 38% while Group 2 is 62% of the total costs. In terms of treatment objectives 51% of the patients in Group 1 after 12 months achieved LDA or remission vs. 23.4% in Group 2. Considering the budget spent to obtain these results, NHIH spent in average 58% more per patient per DAS28 point with Group 2 vs. Group 1.

Conclusion: Switching on RTX after the first anti-TNF failure allows the achievement of a sooner and better EULAR response than RTX therapy after 2 or 3 anti TNF stages. DAS28 decreased consistently for all RTX patients, irrespective of their group, but those in Group 1 achieved a lowest value faster. RTX after first anti-TNF is clearly more efficient, the costs to obtain superior clinical response being almost half of those involved in the second therapeutic option. The savings could be used for higher number of RA treated patients with the same budget and shortening the RA patient’s waiting list. The balance cost-benefits being in favour of initiating a RTX medication after the first anti-TNF therapy (follow NICE recommendation) this is our recommendation for NHIH.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/rituximab-after-first-anti-tumor-necrosis-factor-failure-is-more-efficient-with-high-impact-in-reducing-time-and-costs-to-achieve-superior-rates-of-low-disease-activity-and-remission/