title: Treating to target with etanercept in rheumatoid arthritis: cost-effectiveness of dose reductions when remission is achieved.
abstract: BACKGROUND
  Current management of rheumatoid arthritis (RA) focuses on inducing remission as early as possible to avoid lasting joint damage, and maintenance of remission has become important. A 12-month clinical trial in 834 patients with moderate RA investigated whether etanercept 50 mg/wk could be reduced to half dose or discontinued in patients who achieved low disease activity after 36 weeks.
  
  
  OBJECTIVE
  The objective of this study was to estimate the cost-effectiveness of the three maintenance strategies.
  
  
  METHODS
  A Markov model integrated the three strategies from the clinical trial and extrapolated to 10 years using data from the Swedish RA registry. Assumed treatment strategies after the trial were similar in all three arms, with patients failing to maintain remission on half-dose etanercept or methotrexate alone switching to the full dose of etanercept and patients maintaining remission on full-dose etanercept allowed switching to half dose. Resource use and utilities were taken from an observational study. Results are presented as cost/quality-adjusted life-year (QALY) (both discounted 3%) in the societal perspective.
  
  
  RESULTS
  The cost/QALY gained with half-dose etanercept versus methotrexate ranged from €14,000 to €29,000: Longer simulations result in a higher cost/QALY, as the acquisition cost of etanercept increases. Half-dose etanercept technically dominates the full dose (lower costs [€-3000 to 6300] and similar effectiveness [0.007-0.011]).
  
  
  CONCLUSIONS
  Although ultimately all three strategies explored achieve a similar outcome as all three continuously manage patients to maintain remission, it appears that a dose reduction is the most advantageous strategy in patients with moderate disease activity.
authors.affiliation: University of Lund, Lund, Sweden; European Health Economics, Mulhouse, France. Electronic address: Gisela.Kobelt@he-europe.com.
authors.forename: Gisela
authors.initials: G
authors.lastname: Kobelt
mesh_terms: D018501:Antirheumatic Agents / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000191:economics; D003362:Cost-Benefit Analysis; D004305:Dose-Response Relationship, Drug; D000068800:Etanercept; D006801:Humans; D007074:Immunoglobulin G / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D008390:Markov Chains; D008727:Methotrexate / Q000191:economics / Q000627:therapeutic use; D018803:Models, Economic; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic; D018124:Receptors, Tumor Necrosis Factor / Q000008:administration & dosage / Q000627:therapeutic use*; D012042:Registries; D012074:Remission Induction; D013548:Sweden; D016896:Treatment Outcome
chemical_list: D018501:Antirheumatic Agents; D007074:Immunoglobulin G; D018124:Receptors, Tumor Necrosis Factor; D000068800:Etanercept; D008727:Methotrexate
keywords: cost-effectiveness; etanercept; modeling; remission; rheumatoid arthritis