title: Cost-effectiveness of sequenced treatment of rheumatoid arthritis with targeted immune modulators.
abstract: OBJECTIVE
  To determine the cost-effectiveness of treatment sequences of biologic disease-modifying anti-rheumatic drugs or Janus kinase/STAT pathway inhibitors (collectively referred to as bDMARDs) vs conventional DMARDs (cDMARDs) from the US societal perspective for treatment of patients with moderately to severely active rheumatoid arthritis (RA) with inadequate responses to cDMARDs.
  
  
  METHODS
  An individual patient simulation model was developed that assesses the impact of treatments on disease based on clinical trial data and real-world evidence. Treatment strategies included sequences starting with etanercept, adalimumab, certolizumab, or abatacept. Each of these treatment strategies was compared with cDMARDs. Incremental cost, incremental quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each treatment sequence relative to cDMARDs. The cost-effectiveness of each strategy was determined using a US willingness-to-pay (WTP) threshold of $150,000/QALY.
  
  
  RESULTS
  For the base-case scenario, bDMARD treatment sequences were associated with greater treatment benefit (i.e. more QALYs), lower lost productivity costs, and greater treatment-related costs than cDMARDs. The expected ICERs for bDMARD sequences ranged from ∼$126,000 to $140,000 per QALY gained, which is below the US-specific WTP. Alternative scenarios examining the effects of homogeneous patients, dose increases, increased costs of hospitalization for severely physically impaired patients, and a lower baseline Health Assessment Questionnaire (HAQ) Disability Index score resulted in similar ICERs.
  
  
  CONCLUSIONS
  bDMARD treatment sequences are cost-effective from a US societal perspective.
authors.affiliation: a Precision Health Economics , Oakland , CA , USA.
authors.forename: Jeroen P
authors.initials: JP
authors.lastname: Jansen
authors.affiliation: a Precision Health Economics , Oakland , CA , USA.
authors.forename: Devin
authors.initials: D
authors.lastname: Incerti
authors.affiliation: b Amgen Inc. , Thousand Oaks , CA , USA.
authors.forename: Alex
authors.initials: A
authors.lastname: Mutebi
authors.affiliation: a Precision Health Economics , Oakland , CA , USA.
authors.forename: Desi
authors.initials: D
authors.lastname: Peneva
authors.affiliation: a Precision Health Economics , Oakland , CA , USA.
authors.forename: Joanna P
authors.initials: JP
authors.lastname: MacEwan
authors.affiliation: b Amgen Inc. , Thousand Oaks , CA , USA.
authors.forename: Bradley
authors.initials: B
authors.lastname: Stolshek
authors.affiliation: b Amgen Inc. , Thousand Oaks , CA , USA.
authors.forename: Primal
authors.initials: P
authors.lastname: Kaur
authors.affiliation: b Amgen Inc. , Thousand Oaks , CA , USA.
authors.forename: Mahdi
authors.initials: M
authors.lastname: Gharaibeh
authors.affiliation: c Division of Immunology/Rheumatology , Stanford University , Palo Alto , CA , USA.
authors.forename: Vibeke
authors.initials: V
authors.lastname: Strand
mesh_terms: D000069594:Abatacept / Q000191:economics / Q000627:therapeutic use; D000068879:Adalimumab / Q000191:economics / Q000627:therapeutic use; D000367:Age Factors; D061067:Antibodies, Monoclonal, Humanized / Q000191:economics / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D001688:Biological Products / Q000008:administration & dosage / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D000068582:Certolizumab Pegol / Q000191:economics / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D004359:Drug Therapy, Combination; D000068800:Etanercept / Q000191:economics / Q000627:therapeutic use; D006801:Humans; D000069285:Infliximab / Q000191:economics / Q000627:therapeutic use; D018803:Models, Economic; D010880:Piperidines / Q000191:economics / Q000627:therapeutic use; D011743:Pyrimidines / Q000191:economics / Q000627:therapeutic use; D011758:Pyrroles / Q000191:economics / Q000627:therapeutic use; D019057:Quality-Adjusted Life Years; D012720:Severity of Illness Index; D012737:Sex Factors; D013997:Time Factors; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors; D014481:United States
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D001688:Biological Products; D010880:Piperidines; D011743:Pyrimidines; D011758:Pyrroles; D014409:Tumor Necrosis Factor-alpha; D000069594:Abatacept; C479163:tofacitinib; D000069285:Infliximab; D000068879:Adalimumab; C502936:tocilizumab; D000068800:Etanercept; D000068582:Certolizumab Pegol
keywords: Anti-TNF; Biologics; Cost-effectiveness; DMARD; Disease-modifying anti-rheumatic drug; JAK/STAT pathway inhibitor; Rheumatoid arthritis