Abstract
Recent guideline updates have suggested de-escalating DMARDs when patients with rheumatoid arthritis achieve remission or low disease activity. We aim to evaluate whether it is cost-effective to de-escalate the biological form of DMARDs (bDMARDs). Using a Markov model, we performed a cost-utility analysis for RA patients on bDMARD treatment. We compared continuing treatment (standard care) to a tapering approach (i.e., an immediate 50% dose reduction), withdrawal (i.e., an immediate 100% dose reduction) and tapering followed by withdrawal of bDMARDs. The parametrization is based on a comprehensive literature review. Results were computed for 30 years with a cycle length of three months. We applied the payer's perspective for Germany and conducted deterministic and probabilistic sensitivity analyses. Tapering or withdrawing bDMARD treatment resulted in ICERs of €526,254 (incr. costs -78,845, incr. QALYs -0.1498) or €216,879 (incr. costs -€121,691, incr. QALYs -0.5611) compared to standard care. Tapering followed by withdrawal resulted in a loss of 0.4354 QALYs and savings of €107,969 per patient, with an ICER of €247,987. Deterministic sensitivity analysis revealed that our results remained largely unaffected by parameter changes. Probabilistic sensitivity analysis suggests that tapering, withdrawal and tapering followed by withdrawal were dominant in 39.8%, 28.2% and 29.0% of 10,000 iterations. Our findings suggest that de-escalating bDMARDs in patients with RA may result in high cost savings but also a decrease in quality of life compared to standard care. If decision makers choose to implement de-escalation in daily practice, our results suggest the tapering approach.
Highlights
Rheumatoid Arthritis (RA) is one of the most prevalent chronic inflammatory diseases in North America and Europe [1]
Tapering or withdrawing biological DMARDs (bDMARDs) treatment resulted in incremental cost-effectiveness ratios (ICERs) of €526,254
Our findings suggest that de-escalating bDMARDs in patients with RA may result in high cost savings and a decrease in quality of life compared to standard care
Summary
Rheumatoid Arthritis (RA) is one of the most prevalent chronic inflammatory diseases in North America and Europe [1]. In 2013, the prevalence of RA in Germany was an estimated 1.4%[2]. Treatment follows a treat-to-target approach, which aims for persistent clinical remission or at least low disease activity[3]. Pharmacological treatment consists of analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, conventional synthetic diseasemodifying antirheumatic drugs (csDMARDs), targeted synthetic DMARDs (tsDMARDs), biological DMARDs (bDMARDs), or combination of these. The number of patients treated with the highly effective bDMARDs has increased continuously in the US, Europe and Australia since their introduction in the early 2000s[4]. The share of RA patients treated with bDMARDs in Germany, for example, increased from 4.4% in 2002 [5] to 27.3% in 2014[6]. In 2016, the 41.3 million defined daily doses of bDMARDs prescribed in Germany[7] accounted for more than two billion euros in health care expenditure
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