Cost-effectiveness of drug monitoring of anti-TNF therapy in inflammatory bowel disease and rheumatoid arthritis: a systematic review.
BACKGROUND
Therapeutic drug monitoring (TDM) of anti-TNF is increasingly used to manage inflammatory bowel diseases (IBD) and rheumatoid arthritis (RA). The cost-effectiveness of this strategy is debated.


METHODS
All studies comparing the cost-effectiveness of a TDM-based strategy and an empirical dose management of anti-TNF in IBD or RA were screened. Studies were identified through the MEDLINE electronic database (up to July 2016), and annual international meeting abstracts were also manually reviewed.


RESULTS
Seven studies were included: two randomized controlled trials (RCTs) enrolling 332 patients [247 Crohn's disease (CD) and 85 ulcerative colitis (UC)] and five modeling approaches. Four studies included only CD patients, one included both CD and UC patients, and two included only RA patients. Three studies compared the cost-effectiveness of the two strategies in patients with secondary infliximab (IFX) failure (dose-escalation strategy), one in patients in remission on optimized IFX (de-escalation strategy), one in patients starting adalimumab, and two in patients with clinical response to maintenance anti-TNF therapy. The two RCTs demonstrated that a TDM strategy led to major cost savings, ranging from 28 to 34 %. The three modeling approaches with regard to CD patients demonstrated cost savings ranging from $5396 over a 1-year period to €13,130 per patient at 5 years of follow-up. A TDM strategy also led to major cost savings in the two modeling approaches in RA patients.


CONCLUSIONS
Available evidence indicates that a TDM strategy leads to major cost savings related to anti-TNF therapy in both IBD and RA patients, with no negative impact on efficacy.
Department of Hepato-Gastroenterology, University Hospital of Nancy, Université de Lorraine, Vandoeuvre-lès-Nancy, France.
Laura
L
Martelli
Department of Hepato-Gastroenterology, University Hospital of Nancy, Université de Lorraine, Vandoeuvre-lès-Nancy, France.
Pablo
P
Olivera
Department of Gastroenterology, University Hospital of Saint Etienne, Saint-Étienne, France.
Xavier
X
Roblin
Department of Gastroenterology, IBD, Nutritional Support, Beaujon Hospital, Clichy, France.
Alain
A
Attar
Inserm U954 and Department of Hepato-Gastroenterology, University Hospital of Nancy-Brabois, université de Lorraine, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France. peyrinbiroulet@gmail.com.
Laurent
L
Peyrin-Biroulet
D018501:Antirheumatic Agents / Q000008:administration & dosage / Q000191:economics / Q000494:pharmacology; D001172:Arthritis, Rheumatoid / Q000188:drug therapy / Q000191:economics; D003093:Colitis, Ulcerative / Q000188:drug therapy / Q000191:economics; D003362:Cost-Benefit Analysis; D003424:Crohn Disease / Q000188:drug therapy / Q000191:economics; D016903:Drug Monitoring / Q000191:economics / Q000379:methods*; D005765:Gastrointestinal Agents / Q000008:administration & dosage / Q000191:economics / Q000494:pharmacology; D006801:Humans; D018803:Models, Economic; D016032:Randomized Controlled Trials as Topic; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
D018501:Antirheumatic Agents; D005765:Gastrointestinal Agents; D014409:Tumor Necrosis Factor-alpha
Cost savings; Inflammatory bowel disease; Infliximab; Rheumatoid arthritis; Trough concentrations
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