Treatment of very early rheumatoid arthritis with symptomatic therapy, disease-modifying antirheumatic drugs, or biologic agents: a cost-effectiveness analysis.
BACKGROUND
Long-term control or remission of rheumatoid arthritis (RA) may be possible with very early treatment. However, no optimal first therapeutic strategy has been determined.


OBJECTIVE
To assess the potential cost-effectiveness of major therapeutic strategies for very early RA.


METHODS
Decision analytic model with probabilistic sensitivity analyses.


METHODS
Published data, the National Data Bank for Rheumatic Diseases, and actual 2007 hospital costs.


METHODS
U.S. adults with very early RA (symptom duration <or=3 months).


METHODS
Lifetime.


CONCLUSIONS
Health care provider and societal.


METHODS
3 management strategies were compared: a symptomatic or "pyramid" strategy with initial nonsteroidal anti-inflammatory drugs, patient education, pain management, and low-dose glucocorticoids, and disease-modifying antirheumatic drugs (DMARDs) at 1 year for nonresponders; early DMARD therapy with methotrexate; and early therapy with biologics and methotrexate.


METHODS
Cost per quality-adjusted life-year (QALY) gained.


RESULTS
By reducing the progression of joint erosions and subsequent functional disability, both early intervention strategies increase quality-adjusted life more than the pyramid strategy and save long-term costs. When the cost of very early intervention is factored in, the cost-effectiveness ratio of the early DMARD strategy is $4849 per QALY (95% CI, $0 to $16 354 per QALY) compared with the pyramid strategy, whereas the benefits gained through the early biologic strategy come at a substantial incremental cost. The early DMARD strategy maximizes the effectiveness of early DMARDs and reserves the use of biologics for patients with more treatment-resistant disease of longer duration, for which the incremental benefit of biologics is greater.


RESULTS
The early biologic strategy becomes more cost-effective if drug prices are reduced, risk for death is permanently lowered through biologic therapy, patients experience drug-free remission, responders can be selected before therapy initiation, or effective alternative antirheumatic agents are available for patients for whom several biologics have failed.


CONCLUSIONS
Data on the long-term effect of very early therapeutic interventions on the natural progression in disability and joint erosions are limited. The study considered only tumor necrosis factor inhibitors and not the newer biologics.


CONCLUSIONS
According to the most objective measures of RA progression, very early intervention with conventional DMARDs is cost-effective. The cost-effectiveness of very early intervention with biologics remains uncertain.
Finckh
Axel
A
Division of Rheumatology, Department of Internal Medicine, University of Geneva, Geneva, Switzerland.
Bansback
Nick
N
Marra
Carlo A
CA
Anis
Aslam H
AH
Michaud
Kaleb
K
Lubin
Stanley
S
White
Marc
M
Sizto
Sonia
S
Liang
Matthew H
MH
D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000191:economics / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000191:economics* / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000000981:diagnostic imaging / Q000188:drug therapy*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D018450:Disease Progression; D005938:Glucocorticoids / Q000191:economics / Q000627:therapeutic use; D017048:Health Care Costs; D006801:Humans; D007155:Immunologic Factors / Q000191:economics* / Q000627:therapeutic use*; D008727:Methotrexate / Q000191:economics / Q000627:therapeutic use; D019057:Quality-Adjusted Life Years; D011859:Radiography; D016896:Treatment Outcome
D000894:Anti-Inflammatory Agents, Non-Steroidal; D018501:Antirheumatic Agents; D005938:Glucocorticoids; D007155:Immunologic Factors; D008727:Methotrexate