title: Modeling the 5-year cost effectiveness of treatment strategies including tumor necrosis factor-blocking agents and leflunomide for treating rheumatoid arthritis in the Netherlands.
abstract: OBJECTIVE
  To determine the cost effectiveness of treatment strategies for rheumatoid arthritis patients satisfying the indication for tumor necrosis factor (TNF)-blocking treatment.
  
  
  METHODS
  A Markov model study was performed. The following treatment strategies were considered: 1) usual treatment; 2) treatment with leflunomide, in the case of nonresponse after 3 months, switch to usual treatment; 3) TNF-blocking treatment, in the case of nonresponse after 3 months, switch to usual treatment; 4) treatment with leflunomide, in the case of nonresponse, switch to TNF-blocking treatment, in the case of nonresponse to TNF-blocking treatment, switch to usual treatment; 5) TNF-blocking treatment, in the case of nonresponse, switch to leflunomide treatment, in the case of nonresponse to leflunomide, switch to usual treatment. Expected patient-years in the different Markov states, costs, and quality-adjusted life years (QALYs) were compared between the treatment strategies; incremental cost-effectiveness ratios (ICERs) were calculated.
  
  
  RESULTS
  Over the 5-year period, the expected effect on disease activity and QALYs was better for treatment strategies that included TNF-blocking treatment than for the other treatment strategies. The greater effectiveness of these treatment strategies reduced medical and nonmedical costs compared with usual treatment by about 16% and 33%, respectively, omitting the costs of medication. When the costs of medication were included, the costs of strategies that started with TNF-blocking treatment were higher than those of the other treatment strategies. Treatment strategy 4 had the most favorable ICER of the treatment strategies that included TNF-blocking treatment: 163,556/QALY compared with usual treatment.
  
  
  CONCLUSIONS
  Among strategies that include TNF-blocking agents, one starting with leflunomide and, in the case of nonresponse, switching to TNF-blocking treatment probably results in the most favorable ratio between incremental costs and effects.
authors.affiliation: University Medical Center Nijmegen, Nijmegen, the Netherlands. P.Welsing@reuma.umcn.nl
authors.forename: Paco M J
authors.initials: PM
authors.lastname: Welsing
authors.forename: Johan L
authors.initials: JL
authors.lastname: Severens
authors.forename: Margriet
authors.initials: M
authors.lastname: Hartman
authors.forename: Piet L C M
authors.initials: PL
authors.lastname: van Riel
authors.forename: Roland F J M
authors.initials: RF
authors.lastname: Laan
mesh_terms: D000911:Antibodies, Monoclonal / Q000191:economics* / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000191:economics* / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000188:drug therapy / Q000191:economics*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D007555:Isoxazoles / Q000191:economics* / Q000627:therapeutic use; D000077339:Leflunomide; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D018803:Models, Economic; D009426:Netherlands; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors
chemical_list: D000911:Antibodies, Monoclonal; D018501:Antirheumatic Agents; D007555:Isoxazoles; D014409:Tumor Necrosis Factor-alpha; D000077339:Leflunomide