Switching directly to biologic therapy when methotrexate fails is not cost effective for treating rheumatoid arthritis

1. Biologic therapy had minimal additional benefits for patients compared to triple therapy.

2. When used as a first-line therapy, triple therapy resulted in significantly lower drug costs than biologic therapy.

Evidence Rating Level: 2 (Good)

Study Rundown: Guidelines currently recommend treating rheumatoid arthritis patients with biologic drugs, such as etanercept, following failure of conventional disease modifying anti-rheumatic drugs (DMARDs). However, biologic drugs are highly expensive. Recent studies have suggested that an alternate therapy, known as DMARD triple therapy (sulfasalazine, hydroxychloroquine, and methotrexate), is equally as effective as adding a biologic to methotrexate. Considering these results, the goal of this study was to determine the cost-effectiveness of etancercept-methotrexate, compared to triple therapy, as a first-line strategy for rheumatoid arthritis. Generally, the authors observed that initiating biologic therapy, without trying triple therapy, increases costs without significant benefit. There are several limitations to this study. First, there is limited data regarding the long-term benefits of triple therapy. Second, the model used to assess cost did not account for the possibility of certain adverse effects, which may differ between the 2 different therapies. Overall, the results of this study suggest that triple therapy is an important first-line therapy to initiate prior to switching to biologics.

Click to read the study, published in the Annals of Internal Medicine

Relevant Reading: A randomized comparative effectiveness study of oral triple therapy versus etanercept plus methotrexate in early aggressive rheumatoid arthritis: The Treatment of Early Aggressive Rheumatoid Arthritis trial

In-Depth [retrospective cohort]: The authors conducted a within-trial analysis based on the 353 participants of the Rheumatoid Arthritis Comparison of Active Therapies (RACAT) trial. They also performed a lifetime analysis, allowing them to extrapolate costs and outcomes by using a decision analytic cohort model. The outcomes assessed in this trial included incremental costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). Following the within-trial analysis, it was observed that etanercept-methotrexate, as a first-line treatment, only resulted in marginally more QALYs. In contrast, etanercept-methotrexate had significantly higher drug costs compared to triple therapy. Additionally, the lifetime analysis indicated that first-line etanercept-methotrexate would cost $77 290, at the expense of only a 0.15 additional lifetime QALY.

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