Biologics Before Triple DMARD is Not Cost Effective in Rheumatoid Arthritis Save

Stepping up to biologic therapy when methotrexate (MTX) monotherapy fails was not shown to be cost effective, compared to first trying triple therapy, in a rheumatoid arthritis (RA) study published in Annals of Internal Medicine.

The RACAT (Rheumatoid Arthritis Comparison of Active Therapies) trial was a follow up to the TEAR study, both studying the comparative timing and use of triple therapy (MTX plus hydroxychloroquine plus sulfasalazine) versus etanercept (ETN) and MTX in RA patients failing MTX therapy alone,  Whereas TEAR studied these regimens in early RA patients, RACAT focused on patients with established RA.  Both RACAT and TEAR showed non-inferiority of triple therapy to the more aggressive and expensive biologic regimen (ETN + MTX).

The current study is a subanalysis for the the 353 participants in the RACAT trial and a lifetime analysis that extrapolated costs and outcomes by using a decision analytic cohort model.

MTX inadequate responders were randomized to either ETN-MTX or triple therapy and the incremental costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness rations (ICERs) at 24 months and a lifetime were compared.  

Results showed treating with the biologic therapy first provided marginally more benefits, but an amount that would not be detectable to patients. The lifetime analysis suggested that first-line biologic treatment would result in 0.15 additional lifetime QALYs, but this gain would cost an incremental $77,290, leading to an incremental cost-effectiveness ratio of $521,520 per QALY per patient, a figure far above what is considered acceptable to the U.S. health care system.

The authors conclude that patients, unless contraindicated, should switch to triple therapy first before switching to a biologic strategy. The authors cite literature showing this is a strategy that many patients would prefer anyway, since it could reduce their overall out-of-pocket costs.