Cost-effectiveness of biologic response modifiers compared to disease modifying anti-rheumatic drugs for rheumatoid arthritis: A systematic review

OBJECTIVE:: Biologic response modifiers (biologics) have greater potential to slow the course of rheumatoid arthritis (RA) but cost more than disease-modifying anti-rheumatic drugs (DMARDs). We reviewed the evidence on the cost-effectiveness of biologics compared to DMARDs for RA in adults. METHODS:: Systematic earch of MEDLINE, Embase, NHS EED, OVID HealthStar, Econlit, Tufts CEA Registry from inception to 2008. The British Medical Journal (1996) and Phillips (2006) checklists were used to critically appraise selected articles. Results were stratified by indications for use according to American College of Rheumatology (2008) recommendations. Two acceptable incremental cost-effectiveness ratio (ICER) thresholds were used: CAD 50,000 and 100,000, per quality-adjusted life year (QALY) gain. RESULTS:: Of 918 identified citations, 18 studies were included. Four studies conducted cost-effectiveness analyses, 16 conducted cost-utility analyses, of adalimunab, etanercept, infliximab. The evaluations were limited by lack of evidence, including long-term response to biologics. In DMARD-naive patients, biologic-DMARD sequences were cost-effective for the threshold CAD 100,000/QALY. In patients who failed methotrexate combination therapy or sequentially-administered DMARDs, ICERs were well above CAD 50,000/QALY, while 40% were below CAD 100,000/QALY. In methotrexate monotherapy-resistant patients, all ICERs were below the higher willingness-to-pay threshold; several were below the lower threshold. CONCLUSIONS:: The cost-effectiveness of biologics for RA is not widely demonstrated for the commonly-cited CAD 50,000/QALY threshold; there is mixed evidence for cost-effectiveness at CAD 100,000/QALY. The most cost-effective approach appears to be treatment with a DMARD early in the course of RA, move through a DMARD sequence, and with continued non-response, add a biologic