title: Economic consequences of sequencing biologics in rheumatoid arthritis: a systematic review.
abstract: OBJECTIVE
  Tumor necrosis factor-alpha (anti-TNF) blocking agents are effective for the treatment of rheumatoid arthritis (RA), with mean response rates of 60-70%. Patients with incomplete response to initial anti-TNF treatment often are switched to other biologic treatments with some success. However, little is known about whether or not switching to anti-TNF or other non-TNF biologic treatments is cost-effective. This study sought to review the economic evidence of sequencing various biologic treatments in RA.
  
  
  METHODS
  A systematic review was conducted of published and unpublished literature (January 2000 to October 2012) on the cost-effectiveness of sequencing biologic treatments in RA after failure of an initial biologic treatment. It included modeling and other economic studies that assessed cost-effectiveness of one or more sequences of biologics. Studies were excluded that evaluated non-biologic sequencing.
  
  
  RESULTS
  This review of the available evidence suggests that there is limited evidentiary support favoring the cost-effectiveness of switching from one anti-TNF agent to another within the anti-TNF category of biologics. This is due, in large part, to the limited clinical evidence base supporting the incremental efficacy of second- and third-line anti-TNF treatments and to variation on how and when to assess non-response to the first-line biologic. When compared to anti-TNF agents, biologic treatments with a different mechanism of action are more cost-effective as second-line agents.
  
  
  CONCLUSIONS
  Not all sequences and patterns of switching, either within or outside of therapeutic class, have been evaluated for clinical benefit and cost-effectiveness, limiting the interpretation of these findings.
  
  
  CONCLUSIONS
  Switching from one anti-TNF agent to another after first-line treatment failure may not be a cost-effective treatment strategy. However, when non-TNF biologics are included in the sequence they are likely to be more cost-effective than anti-TNF specific cycling sequences.
authors.affiliation: Pharmaceutical Outcomes Research and Policy Program, School of Pharmacy, University of Washington, Seattle, WA 98195-7630, USA. sdsull@u.washington.edu
authors.forename: Sean D
authors.initials: SD
authors.lastname: Sullivan
authors.forename: Rafael
authors.initials: R
authors.lastname: Alfonso-Cristancho
authors.forename: Josh
authors.initials: J
authors.lastname: Carlson
authors.forename: Usha
authors.initials: U
authors.lastname: Mallya
authors.forename: Sarah
authors.initials: S
authors.lastname: Ringold
mesh_terms: D018501:Antirheumatic Agents / Q000191:economics* / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D001688:Biological Products / Q000191:economics* / Q000627:therapeutic use; D057915:Drug Substitution / Q000191:economics*; D006801:Humans; D017211:Treatment Failure; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products; D014409:Tumor Necrosis Factor-alpha