title: Infliximab dose escalation vs. initiation of adalimumab for loss of response in Crohn's disease: a cost-effectiveness analysis.
abstract: BACKGROUND
  Crohn's disease patients who have lost response to 5 mg/kg of infliximab may regain response by increasing the dose of infliximab to 10 mg/kg. Alternatively, adalimumab can be used as a rescue therapy.
  
  
  OBJECTIVE
  To determine whether dose escalation of infliximab was a cost-effective strategy compared with adalimumab initiation after loss of response to 5 mg/kg of infliximab.
  
  
  METHODS
  A decision-analysis model simulated two cohorts of Crohn's patients: (i) infliximab dose was escalated to 10 mg/kg and (ii) infliximab was discontinued and patients were started on adalimumab. The time horizon was 1 year. One- and two-way sensitivity analyses were performed.
  
  
  RESULTS
  The infliximab dose escalation strategy yielded more quality-adjusted life years (0.79) compared with the adalimumab strategy (0.76). The incremental cost-effectiveness ratio was $332,032/quality-adjusted life year. Sensitivity analysis demonstrated that the model findings were robust. The most significant variables were the cost of infliximab and that of adalimumab, such that a reduction in the cost of infliximab by 1/3 resulted in an incremental cost-effectiveness ratio below $80,000/quality-adjusted life year.
  
  
  CONCLUSIONS
  After a Crohn's patient has lost response to 5 mg/kg of infliximab, dose escalation will yield more quality-adjusted life-year compared with switching to adaliumamb; however, the cost was considerable.
authors.affiliation: Massachusetts General Hospital, Gastrointestinal Unit, Boston, MA, USA.
authors.forename: G G
authors.initials: GG
authors.lastname: Kaplan
authors.forename: C
authors.initials: C
authors.lastname: Hur
authors.forename: J
authors.initials: J
authors.lastname: Korzenik
authors.forename: B E
authors.initials: BE
authors.lastname: Sands
mesh_terms: D000068879:Adalimumab; D000328:Adult; D000911:Antibodies, Monoclonal / Q000008:administration & dosage* / Q000191:economics / Q000627:therapeutic use*; D061067:Antibodies, Monoclonal, Humanized; D003362:Cost-Benefit Analysis; D003424:Crohn Disease / Q000188:drug therapy*; D003661:Decision Support Techniques; D017048:Health Care Costs; D006801:Humans; D000069285:Infliximab; D019057:Quality-Adjusted Life Years
chemical_list: D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D000069285:Infliximab; D000068879:Adalimumab