Cost-effectiveness of different treat-to-target strategies in rheumatoid arthritis: results from the DREAM registry

Celine J Van De Laar,Harald E Vonkeman,Martijn A H Oude Voshaar

doi:10.1186/s41927-019-0064-9

Celine J Van De Laar, Harald E Vonkeman + Show 1 more

Open Access

https://doi.org/10.1186/s41927-019-0064-9

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Abstract

BackgroundAdjusting medication of patients with rheumatoid arthritis (RA) until predefined disease activity targets are met, i.e. Treat-to-Target (T2T), is the currently recommended treatment approach. However, not much is known about long-term cost-effectiveness of different T2T strategies.We model the 5-year costs and effects of a step-up approach (MTX mono - > MTX + csDMARD combination - > Adalimumab - > second anti-TNF) and an initial combination therapy approach (MTX + csDMARD - > MTX + csDMARD higher dose - > anti-TNFs) from the healthcare and societal perspectives, by adapting a previously validated Markov model.MethodsWe constructed a Markov model in which 3-monthly transitions between DAS28-defined health states of remission (≤2.6), low (2.6 < DAS28 ≤ 3.2), moderate (3.2 < DAS28 ≤ 5.1), and high disease activity (DAS28 > 5.1) were simulated. Modelled patients proceeded to subsequent treatments in case of non-remission at each (3-month) cycle start. In case of remission for two consecutive cycles medication was tapered, until medication-free remission was achieved. Transition probabilities for individual treatment steps were estimated using data of Dutch Rheumatology Monitoring registry Remission Induction Cohort I (step-up) and II (initial combination). Expected costs, utility, and ICER after 5 years were compared between the two strategies. To account for parameter uncertainty, probabilistic sensitivity analysis was employed through Gamma, Normal, and Dirichlet distributions. All utilities, costs, and transition probabilities were replaced by fitted distributions.ResultsOver a 5-year timespan, initial combination therapy was less costly and more effective than step-up therapy. Initial combination therapy accrued €16,226.3 and 3.552 QALY vs €20,183.3 and 3.517 QALYs for step-up therapy. This resulted in a negative ICER, indicating that initial combination therapy was both less costly and more effective in terms of utility gained. This can be explained by higher (±5%) remission percentages in initial combination strategy at all time points. More patients in remission generates less healthcare and productivity loss costs and higher utility. Additionally, higher remission percentages caused less bDMARD use in the initial combination strategy, lowering overall costs.ConclusionInitial combination therapy was found favourable over step-up therapy in the treatment of Rheumatoid Arthritis, when considering cost-effectiveness. Initial combination therapy resulted in more utility at a lower cost over 5 years.

Highlights

Adjusting medication of patients with rheumatoid arthritis (RA) until predefined disease activity targets are met, i.e. Treat-to-Target (T2T), is the currently recommended treatment approach
Comparison of model predicted- and clinically observed disease activity outcomes over 5 years Figure 2 presents the distribution of the modelled patients over the four disease activity score in 28 joints (DAS28) states for each of the twenty 3-monthly cycles, compared with the distribution of patient over the disease activity states as observed in daily clinical practice in Remission Induction Cohort (RIC) I [11]
Comparison yields similar results when comparing the result of the initial combination strategy with result from RIC Remission Induction Cohort II (II)

Summary

Introduction

Adjusting medication of patients with rheumatoid arthritis (RA) until predefined disease activity targets are met, i.e. Treat-to-Target (T2T), is the currently recommended treatment approach. The approach currently recommended for RA treatment involves titrating medication dosages until pre-specified disease activity targets (either remission and low disease activity (LDA) or LDA) have been met and maintaining these targets over time. Such so-called treat to target strategies (T2T) have proven to be more effective and to generate more utility than usual care [3, 4]. Even when following these guidelines, different treatment strategies can be adopted, for example T2T protocols employing step-up therapy, initial combination therapy or initial biological DMARDs therapy These differences may lead to important variation in clinical outcomes, costs, and utility

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