title: Consensus development on eligibility of government subsidisation of biologic disease modifying anti-rheumatic agents for treatment of ankylosing spondylitis: The Singapore experience.
abstract: BACKGROUND
  The beneficial effects of biologic disease-modifying anti-rheumatic drugs (bDMARDs), such as tumour necrosis factor inhibitors (anti-TNF) in active ankylosing spondylitis (AS) are well established. The significant costs on patients in the absence of financial subsidization can limit their use. The objective was to describe a consensus development process on recommendations for government-assisted funding of biologic therapy for AS patients in Singapore.
  
  
  METHODS
  Evidence synthesis followed by a modified RAND/UCLA Appropriateness Method (RAM) was used. Eleven rheumatologists rated indications for therapies for different proposed clinical scenarios. Points reflecting the output from the formal group consensus were used to formulate 10 practice recommendations.
  
  
  RESULTS
  It was agreed that a bDMARD (anti-TNF) is indicated if a patient has active AS with a Bath Ankylosing Spondylitis Activity Index (BASDAI) ≥ 4 and spinal pain of ≥ 4 cm on visual analogue scale (VAS) on two occasions at least 12 weeks apart, despite being on a minimum of two sequential non-steroidal anti-inflammatory drugs at maximal tolerated dose for at least 4 weeks, in addition to adherence to an appropriate physiotherapy program for at least 3 months. To qualify for continued biologic therapy, a patient must have documentation of response every 3 months and at least 50% improvement in BASDAI and reduction of spinal pain VAS ≥ 2 cm.
  
  
  CONCLUSIONS
  A validated and feasible consensus process can enable pragmatic standardized recommendations to be developed for bDMARD subsidization for AS patients in a local Asian context.
authors.affiliation: Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore.|Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Peter P
authors.initials: PP
authors.lastname: Cheung
authors.affiliation: Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore.|Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Manjari
authors.initials: M
authors.lastname: Lahiri
authors.affiliation: Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore.|Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Gim-Gee
authors.initials: GG
authors.lastname: Teng
authors.affiliation: Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.
authors.forename: Nai-Lee
authors.initials: NL
authors.lastname: Lui
authors.affiliation: Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore.
authors.forename: Faith L
authors.initials: FL
authors.lastname: Chia
authors.affiliation: Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore.|Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Dow-Rhoon
authors.initials: DR
authors.lastname: Koh
authors.affiliation: Koh Wei Howe Arthritis & Rheumatism Medical Clinic, Mount Elizabeth Medical Centre, Singapore.
authors.forename: Wei-Howe
authors.initials: WH
authors.lastname: Koh
authors.affiliation: Department of Medicine, Khoo Teck Puat Hospital, Singapore.
authors.forename: Swee-Cheng
authors.initials: SC
authors.lastname: Ng
authors.affiliation: Department of Medicine, Alexandra Hospital (Jurong Health), Singapore.
authors.forename: Ernest
authors.initials: E
authors.lastname: Suresh
authors.affiliation: Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore.
authors.forename: Khai-Pang
authors.initials: KP
authors.lastname: Leong
authors.affiliation: Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore.|Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Anita Y N
authors.initials: AYN
authors.lastname: Lim
authors.affiliation: Koh Wei Howe Arthritis & Rheumatism Medical Clinic, Mount Elizabeth Medical Centre, Singapore.
authors.forename: Julian
authors.initials: J
authors.lastname: Thumboo
authors.affiliation: Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore.|Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Tang-Ching
authors.initials: TC
authors.lastname: Lau
authors.affiliation: Leong Keng Hong Arthritis and Medical Clinic, Gleneagles Medical Centre, Singapore.
authors.forename: Keng-Hong
authors.initials: KH
authors.lastname: Leong
mesh_terms: D018501:Antirheumatic Agents / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D001688:Biological Products / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D032921:Consensus; D016527:Drug Costs / Q000331:legislation & jurisprudence; D004608:Eligibility Determination / Q000191:economics* / Q000331:legislation & jurisprudence; D005380:Financing, Government / Q000191:economics* / Q000331:legislation & jurisprudence; D033161:Government Regulation; D005102:Health Expenditures / Q000331:legislation & jurisprudence; D006801:Humans; D009313:National Health Programs / Q000191:economics* / Q000331:legislation & jurisprudence; D011050:Policy Making; D012846:Singapore; D013167:Spondylitis, Ankylosing / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics* / Q000276:immunology
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products
keywords: ankylosing spondylitis; anti-TNF; biologics; government; spondyloarthritis; subsidy