In the JournalsPerspective

DMARDs more cost effective, achieve similar outcomes vs. TNF inhibitors in RA

Anita Patel

Initiating treatment with intensive combinations of conventional disease modifying antirheumatic drugs achieves comparable outcomes as treatment with TNF inhibitors, but at a significantly lower cost, among patients with rheumatoid arthritis, according to data published in Arthritis Care & Research.

“This study is important because biologic drugs like TNF inhibitors are substantially more expensive than conventional DMARDs,” Anita Patel, PhD, of Anita Patel Health Economics Consulting, told Healio Rheumatology. “It is thus legitimate to question what additional value they bring, especially for resource-limited health care systems.”

To analyze whether intensive combinations of conventional DMARDs could result in clinical benefits similar to TNF inhibitors, but for a lower price, in patients with active RA, Patel and colleagues conducted a pre-planned economic evaluation within the larger TACIT trial. According to the researchers, the TACIT trial was an open-label, 12-month, pragmatic, randomized, multicenter noninferiority study that compared conventional DMARD and TNF inhibitors treatment strategies for RA. Participants included 101 patients in the TNF inhibitor group and 104 in the conventional DMARD cohort, all of whom had previously failed to respond to methotrexate and another DMARD.

Image of arthritic hand 
Initiating treatment with intensive combinations of conventional DMARDs achieves comparable outcomes as treatment with TNF inhibitors, but at a significantly lower cost, among patients with RA, according to data.
Source: Adobe

Patel and colleagues determined cost effectiveness using the trial’s primary outcome measure, the health assessment questionnaire, with cost-utility analyses based on quality-adjusted life years, derived from the Short Form 36 (SF-36) and the EuroQuol 5-Dimension measure (EQ5D3L). These measures were administered at baseline as well as 6 and 12 months. Participants in the conventional DMARD group who demonstrated poor responses to treatment at 6 months were offered the opportunity to switch to TNF inhibitors treatment. A total of 46 patients opted to switch.

In the final analysis, relevant cost and outcome data were available for 93% of participants at 6 months, and for 91% to 92% at 12 months.

According to the researchers, patients in the conventional DMARD group experienced significantly lower cost totals from all perspectives (6-month health and social care adjusted mean difference = –£3,615; 95% CI, –4,104 to –3,182). In addition, analysis of health assessment questionnaires demonstrated benefit to conventional DMARD treatment at 12 months (–0.16; 95% CI, –0.32 to –0.01). No other differences were observed in additional outcomes or follow-ups.

“For patients with established RA who have failed to respond to methotrexate and another DMARD, starting treatment with conventional DMARDs provides equivalent outcomes to starting treatment with TNF inhibitors at 12 months, and either avoids or delays the additional costs associated with the more expensive TNF inhibitors,” Patel said. “Such a treatment strategy therefore offers a pragmatic response to financial challenges presented by new and more expensive treatments.” – by Jason Laday

Disclosure: Patel reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Anita Patel

Initiating treatment with intensive combinations of conventional disease modifying antirheumatic drugs achieves comparable outcomes as treatment with TNF inhibitors, but at a significantly lower cost, among patients with rheumatoid arthritis, according to data published in Arthritis Care & Research.

“This study is important because biologic drugs like TNF inhibitors are substantially more expensive than conventional DMARDs,” Anita Patel, PhD, of Anita Patel Health Economics Consulting, told Healio Rheumatology. “It is thus legitimate to question what additional value they bring, especially for resource-limited health care systems.”

To analyze whether intensive combinations of conventional DMARDs could result in clinical benefits similar to TNF inhibitors, but for a lower price, in patients with active RA, Patel and colleagues conducted a pre-planned economic evaluation within the larger TACIT trial. According to the researchers, the TACIT trial was an open-label, 12-month, pragmatic, randomized, multicenter noninferiority study that compared conventional DMARD and TNF inhibitors treatment strategies for RA. Participants included 101 patients in the TNF inhibitor group and 104 in the conventional DMARD cohort, all of whom had previously failed to respond to methotrexate and another DMARD.

Image of arthritic hand 
Initiating treatment with intensive combinations of conventional DMARDs achieves comparable outcomes as treatment with TNF inhibitors, but at a significantly lower cost, among patients with RA, according to data.
Source: Adobe

Patel and colleagues determined cost effectiveness using the trial’s primary outcome measure, the health assessment questionnaire, with cost-utility analyses based on quality-adjusted life years, derived from the Short Form 36 (SF-36) and the EuroQuol 5-Dimension measure (EQ5D3L). These measures were administered at baseline as well as 6 and 12 months. Participants in the conventional DMARD group who demonstrated poor responses to treatment at 6 months were offered the opportunity to switch to TNF inhibitors treatment. A total of 46 patients opted to switch.

In the final analysis, relevant cost and outcome data were available for 93% of participants at 6 months, and for 91% to 92% at 12 months.

According to the researchers, patients in the conventional DMARD group experienced significantly lower cost totals from all perspectives (6-month health and social care adjusted mean difference = –£3,615; 95% CI, –4,104 to –3,182). In addition, analysis of health assessment questionnaires demonstrated benefit to conventional DMARD treatment at 12 months (–0.16; 95% CI, –0.32 to –0.01). No other differences were observed in additional outcomes or follow-ups.

“For patients with established RA who have failed to respond to methotrexate and another DMARD, starting treatment with conventional DMARDs provides equivalent outcomes to starting treatment with TNF inhibitors at 12 months, and either avoids or delays the additional costs associated with the more expensive TNF inhibitors,” Patel said. “Such a treatment strategy therefore offers a pragmatic response to financial challenges presented by new and more expensive treatments.” – by Jason Laday

Disclosure: Patel reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Alan L. Epstein

    Alan L. Epstein

    Over the past 20 years new therapeutic options have emerged, greatly improving the prognosis of patients with rheumatoid arthritis; however, these new treatments are quite costly, making the care of a patient with this disease extremely expensive.

    Methotrexate is a very effective and economical first-line option, with several studies demonstrating that approximately 30% of patients with active rheumatoid arthritis achieve an adequate response to methotrexate monotherapy. For the 70% of patients who have an inadequate response to methotrexate monotherapy, there are numerous therapies that — when added to methotrexate — have been shown to be superior to methotrexate alone. However, since some of these options use conventional synthetic DMARDs while others use biologic or targeted synthetic DMARD therapy, there exist very different economic implications.

    In the TACIT trial, 205 patients from England and Wales were recruited into an open-label, 12-month, pragmatic, randomized multicenter trial comparing the efficacy and cost effectiveness of treating patients with combinations of conventional DMARDs vs. combination therapy with a TNF inhibitor. Clinical outcomes, reported elsewhere, showed that both arms were noninferior; the pre-planned economic evaluation presented here shows that treatment with combinations of conventional DMARDs is cost effective when compared to treatment with combination therapy that includes a TNF inhibitor.

    To say that combinations of conventional DMARDs are more cost effective implies that the two treatment options are comparably effective, as demonstrated here. Clinical comparability was also demonstrated by O’Dell and colleagues in the RACAT trial, in which triple therapy with methotrexate, sulfasalazine and hydroxychloroquine was shown to be noninferior to etanercept and methotrexate.

    Other data, however, demonstrate that the increased utilization of biologic therapies is associated with lower rates of disability. In the TEAR trial, Moreland and colleagues demonstrate clinical noninferiority between triple therapy and etanercept/methotrexate, but there was more radiographic progression in the group of patients receiving triple therapy. Since radiographic progression drives disability, does this mean that the patients receiving triple therapy will suffer more disability? If this is indeed the case, there are additional economic consequences to be considered. Bottom line: We need more clinical outcomes data to fully answer this question.

    • Alan L. Epstein, MD
    • Clinical professor of medicine
      Perelman School of Medicine
      University of Pennsylvania
      Faculty member, Congress of Clinical Rheumatology

    Disclosures: Epstein reports no relevant financial disclosures.