title: Cost-utility of different treatment strategies after the failure of tumour necrosis factor inhibitor in rheumatoid arthritis in the Finnish setting.
abstract: OBJECTIVE
  To evaluate the cost-utility of different treatment strategies in severe RA after TNF-inhibitor failure.
  
  
  METHODS
  The cost-effectiveness of treatment strategies was compared in a group of hypothetical Finnish RA patients. Initially, the patients received either best supportive care (BSC) or one of the following treatments before BSC: adalimumab (ADAL), abatacept (ABAT), etanercept (ETAN), infliximab (INFL) or rituximab (RTX). Further treatments were added to the most cost-effective strategy in a stepwise manner. The analysis was performed on an Excel-based Markov state transition model using the probabilistic approach. The clinical outcomes related to treatments were estimated from published clinical trials. The gained quality-adjusted life-years (QALYs) were estimated based on Health Utilities Index (HUI-3) and disease severity scores (HAQ). The resource use and costs were obtained from the Finnish treatment practice, one published study, the Finnish Unit Cost list and Finnish Medicine Tariffs.
  
  
  RESULTS
  Treatment with RTX was more effective and less costly than treatment with ADAL, ABAT or ETAN after TNF-inhibitor failure. An additional QALY gained with RTX costs 30,248 euros compared with BSC. The incremental cost-effectiveness ratios (ICERs) are 50,941, 50,372, 36,121 and 67,003 euros per QALY gained for adding ADAL, ETAN, INFL and ABAT to the RTX strategy, respectively. According to the cost-effectiveness acceptability frontier (CEAF), only BSC or treatments with RTX or RTX followed by INFL should be considered after TNF-inhibitor failure, if willingness to pay is between 0 and 50,000 euros per QALY gained.
  
  
  CONCLUSIONS
  Treatment with RTX is a cost-effective treatment strategy in RA patients in Finland.
authors.affiliation: ESiOR Oy, Kuopio, Finland. taru.hallinen@esior.fi
authors.forename: Taru A
authors.initials: TA
authors.lastname: Hallinen
authors.forename: Erkki J O
authors.initials: EJ
authors.lastname: Soini
authors.forename: Kari
authors.initials: K
authors.lastname: Eklund
authors.forename: Kari
authors.initials: K
authors.lastname: Puolakka
mesh_terms: D000068879:Adalimumab; D000328:Adult; D000911:Antibodies, Monoclonal / Q000191:economics* / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized; D058846:Antibodies, Monoclonal, Murine-Derived / Q000191:economics / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000191:economics* / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000191:economics; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D005260:Female; D005387:Finland; D017048:Health Care Costs; D006801:Humans; D000069285:Infliximab; D008297:Male; D008875:Middle Aged; D008954:Models, Biological; D019057:Quality-Adjusted Life Years; D000069283:Rituximab; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome; D000079424:Tumor Necrosis Factor Inhibitors; D048069:Tumor Necrosis Factors / Q000191:economics / Q000627:therapeutic use
chemical_list: D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D058846:Antibodies, Monoclonal, Murine-Derived; D018501:Antirheumatic Agents; D000079424:Tumor Necrosis Factor Inhibitors; D048069:Tumor Necrosis Factors; D000069283:Rituximab; D000069285:Infliximab; D000068879:Adalimumab