Long-term control or remission of rheumatoid arthritis (RA) may be possible with very early treatment. However, no optimal first therapeutic strategy has been determined. ⋯ According to the most objective measures of RA progression, very early intervention with conventional DMARDs is cost-effective. The cost-effectiveness of very early intervention with biologics remains uncertain.
Axel Finckh, Nick Bansback, Carlo A Marra, Aslam H Anis, Kaleb Michaud, Stanley Lubin, Marc White, Sonia Sizto, and Matthew H Liang.
Division of Rheumatology, Department of Internal Medicine, University of Geneva, Geneva, Switzerland.
Ann. Intern. Med. 2009 Nov 3; 151 (9): 612-21.
BackgroundLong-term control or remission of rheumatoid arthritis (RA) may be possible with very early treatment. However, no optimal first therapeutic strategy has been determined.ObjectiveTo assess the potential cost-effectiveness of major therapeutic strategies for very early RA.DesignDecision analytic model with probabilistic sensitivity analyses.Data SourcesPublished data, the National Data Bank for Rheumatic Diseases, and actual 2007 hospital costs.Target PopulationU.S. adults with very early RA (symptom duration Time HorizonLifetime.PerspectiveHealth care provider and societal.Intervention3 management strategies were compared: a symptomatic or "pyramid" strategy with initial nonsteroidal anti-inflammatory drugs, patient education, pain management, and low-dose glucocorticoids, and disease-modifying antirheumatic drugs (DMARDs) at 1 year for nonresponders; early DMARD therapy with methotrexate; and early therapy with biologics and methotrexate.Outcome MeasuresCost per quality-adjusted life-year (QALY) gained.Results Of Base Case AnalysisBy reducing the progression of joint erosions and subsequent functional disability, both early intervention strategies increase quality-adjusted life more than the pyramid strategy and save long-term costs. When the cost of very early intervention is factored in, the cost-effectiveness ratio of the early DMARD strategy is $4849 per QALY (95% CI, $0 to $16 354 per QALY) compared with the pyramid strategy, whereas the benefits gained through the early biologic strategy come at a substantial incremental cost. The early DMARD strategy maximizes the effectiveness of early DMARDs and reserves the use of biologics for patients with more treatment-resistant disease of longer duration, for which the incremental benefit of biologics is greater.Results Of Sensitivity AnalysisThe early biologic strategy becomes more cost-effective if drug prices are reduced, risk for death is permanently lowered through biologic therapy, patients experience drug-free remission, responders can be selected before therapy initiation, or effective alternative antirheumatic agents are available for patients for whom several biologics have failed.LimitationsData on the long-term effect of very early therapeutic interventions on the natural progression in disability and joint erosions are limited. The study considered only tumor necrosis factor inhibitors and not the newer biologics.ConclusionAccording to the most objective measures of RA progression, very early intervention with conventional DMARDs is cost-effective. The cost-effectiveness of very early intervention with biologics remains uncertain.