Mean costs per day in RS and LDAS were, respectively, €829 and €428 for the biologic sequence composed of ADA-ABA-ETA, €1292 and €516 for the sequence ADA-RTX-ETA, €829 and €429 for the sequence ETA-ABA-ADA, €1292 and €517 for the sequence ETA-RTX- ADA, €840 and €434 for the sequence INF-ABA-ETA, and €1309 and €523 for the sequence INF-RTX-ETA.
In moderate or severe RA when a clinical response to a first TNF-blocker, (ETA, ADA, or INF), is insufficient, the treatment sequences including ABA as the second biologic option appear more cost effective than those including RTX.
ABA versus RTX and ABA versus sequential anti-TNF agents (>2)
ICER per day in LDAS: ABA (after one anti-TNF agent) more cost effective versus RTX (€376 versus €456). ABA used (after two anti-TNF agents) more cost effective versus sequential anti-TNF use (€642 versus €1164).
Moderate-to-severe active RA after an insufficient response to anti-TNF agents. ABA appears to be more cost effective than other compared regimes.
ABA was estimated to yield 1.06 additional quality-adjusted life years (QALYs) per patient (3.28 versus 2.22) over a lifetime, compared to conventional DMARDs. The total lifetime costs associated with ABA were £46,522 and total costs for conventional DMARDs were £17,025, resulting in an incremental cost-effectiveness ratio (ICER) of £27,936 per QALY gained. Probabilistic and univariate sensitivity analyses confirmed the robustness of our findings.
Abatacept is a cost-effective treatment option for patients with RA after the failure of a first anti-TNF in the UK.
Relative to placebo, ABA therapy was estimated to yield an average of 1.07 additional QALY per patient, at a mean incremental cost of $45,875; RTX therapy was estimated to yield an average of 0.94 (95% CI = 0.82, 1.05) additional QALY per patient, at a mean incremental cost of $51,101. Lifetime treatment with ABA was estimated to be a dominant strategy compared with RTX, primarily due to lower treatment costs and better HAQ improvement.
ABA therapy would be economically attractive from a Canadian payer perspective.
RTX therapy resulted in a total annual cost of R$46,388 per patient. Total annual costs per patient for the comparators were R$79,394 for INF, R$90,831 for ADA, R$120,351 for ETA, and R$77,118 for ABA. In the BIA, RTX therapy resulted in total savings of R$94,201,413 in 5 years considering the population in the private health care system only. Results were sensitive to dosage schedule (RTX, INF, and ABA) and drug costs.
In patients with IR to anti-TNF. The study assumed equal efficacy and assessed the total cost of RTX therapy in comparison with INF, ADA, ETA, and ABA. RTX is a dominant alternative.
The simulated effect of a progressive replacement (16%, 50%, and 100% at years 1, 5, and 10, resp.) of the current strategy with the two new strategies yielded the following results. RTX therapy induces a decrease of costs of 1.16 million Euro (−7.1% with respect to current strategy), 4.91 (−7.7%), and 4.94 (−5.3%) at years 1, 5, and 10, whereas ABA therapy induces an increase of 0.6 million Euro (+3.7%), 5.43 (+8.5%), and 20.62 (22.2%).
When only direct medical costs were considered, the direct comparison between the two new strategies, RTX results less expensive.
ABA (as second biologic agent—Strategy A) versus RTX (as second biologic agent—Strategy B).
Using the LDAS endpoint, Strategy A was significantly more efficacious over 2 years versus Strategy B, with 134 versus 107 TEND under LDAS. Mean cost-effectiveness ratios showed significantly lower overall medical costs per TEND under LDAS with Strategy A versus Strategy B (€212 versus €234). Using the remission endpoint, Strategy A was significantly more efficacious over 2 years versus Strategy B, with 61 versus 37 TEND under remission. Mean cost-effectiveness ratios showed significantly lower overall medical costs per TEND under remission with Strategy A versus Strategy B (€446 versus €642; ).
Moderate to severely active RA and an inadequate response to anti-TNF therapy. When used as the second biologic agent after an inadequate response to one anti-TNF agent, ABA appears significantly more efficacious and cost effective than RTX.
ABA versus anti-TNF therapies was estimated to yield 0.66 additional QALYs per patient at an incremental cost of €10,096.40, based on a 20 years’ time horizon. Cost per QALY gained was €15,278.20. The acceptability curve showed that ABA has a likelihood of 100% to be cost-effective in comparison to anti-TNFs with willingness-to-pay threshold of €30,000.00.
Compared to anti-TNF therapies, ABA is cost effective in moderately to severely active RA and an insufficient response or intolerance to anti-TNF therapies.
ABA was cost effective compared to MTX, yielding 0.57 additional QALY at cost of 2.03 million HUF with an ICER of 3.6 million HUF/QALY. From the Hungarian health insurance perspective, ICER was 4.4 million HUF/QALY gained. Compared to cycled anti-TNFs, ABA was dominant, with a QALY gain of 0.48 and estimated savings of HUF 731113. From the Hungarian health insurance perspective, the savings were 479 815 HUF. The results are robust to extensive sensitivity analyses.
RA patients with an inadequate response to anti-TNFs: A simulation cost-utility model based on disease progression expressed in HAQ disability index score change was developed to enroll patients corresponding to the patients of the ATTAIN clinical trial. This cost-utility analysis was conducted using a societal perspective, including all costs (direct and indirect). The results of this cost-utility assessment suggest that ABA is cost-effective compared to MTX and to cycled anti-TNFs in Hungary.
Total RA-related health care costs (RTX = $26,783; ABA = $24,344; INF = $27,053; ), RA medication costs (RTX = $19,973; ABA = $19,000; INF = $20,763; ), and Index biologic costs (RTX = $17,638; ABA = $16,233; INF = $17,845; ).
From a U.S. commercial payer perspective No significant difference in one-year RA-medication costs or total RA-related costs between patients starting RTX, ABA, or INF was identified. ABA was associated with lowest costs.
Assuming an IR to the 1st anti-TNF agent, Sequence 1 included ETA-ABA-ADA and Sequence 2 ETA-RTX-ADA. Assuming an IR to 2 anti-TNF agents, Sequence 3 included ETA-ADA-ABA and Sequence 4 ETA-ADA-INF.
There were 6-month medical costs (excluding biologic drug costs) estimated at £1047 (Standard Deviation (SD) 332) for managing patients in LDAS and at £2650 (SD 963) for moderate-to-high disease activity. Over 2 years, Sequence 1 appeared more efficacious (92 days in LDAS) versus Sequence 2 (82 days in LDAS), with cost-effectiveness ratios of £281/day in LDAS versus £289/day in LDAS, respectively. Sequence 3 appeared more efficacious (43 days in LDAS or) versus Sequence 4 (32 days in LDAS), with cost-effectiveness ratios of £603/day in LDAS versus £809/day in LDAS, respectively.
The results of this simulation model suggest that, for achieving LDAS, sequences including ABA after an IR to at least 1 anti-TNF agent appear more cost-effective than similar sequences including RTX or cycled anti-TNF agents.
Four sequential biologic strategies composed of anti-TNF agents versus ABA or RTX
Over 2 years, the sequence with ABA after 1 anti-TNF agent appeared the most effective and cost effective versus use after 2 anti-TNF agents (633 versus 1067/day in LDAS and 1222 versus 3592/day in remission) and versus a similar sequence using RTX (633 versus 728/day in LDAS and 1222 versus 1812/day in remission). The sequence using a 3rd anti-TNF agent was less effective and cost effective than the same sequence using ABA (2000 versus 1067/day in LDAS and 6623 versus 3592/day in remission).
The results suggest that in patients with an IR to at least one anti-TNF agent, biologic sequences including ABA appear more efficacious and cost-effective than similar sequences including RTX or cycled anti TNF agents.
Six treatment strategies using three successive biologic agents ETA, ADA, INF, ABA, RTX
Considering an IR to 1 anti-TNF agent, the sequence ETA-ABA-ADA was more efficacious and cost effective (102 days in LDAS; 496 TL per day in LDAS) over 2 years than the sequence ETA-RTX-ADA (82 days in LDAS; 554 TL per day in LDAS or 81 days in LDAS; 563 TL/day in LDAS based on RTX current reimbursement status). Considering an IR after 2 anti-TNF agents, the sequences ETA-ADA-ABA and ETA-INF-ABA were more efficacious and cost effective (64 days in LDAS for both; 841 and 826 TL/day in LDAS, respectively) over 2 years than a sequence of anti-TNF agents only (32 days in LDAS; 1480 TL per day in LDAS).
Sequences including ABA after an IR to one anti-TNF agent are more efficacious and cost-effective versus similar sequences including RTX. Sequences including ABA after an IR to 2 anti-TNF agents also appear more effective and cost effective than similar sequences composed of anti-TNF agents only.
The introduction of RTX following failure of one biologic resulted in a gain of 0.443 QALYs at an additional total cost of $3710 resulting in an ICER of $8380/QALY. The introduction of ABA following failure of one biologic resulted in a gain of 0.387 QALYs at an additional total cost of $18,588 resulting in an ICER of $48,000/QALY.
RTX is economically attractive from a Canadian payer perspective and is a cost-effective treatment option over ABA when compared in the studied population.
Annual drug acquisition and administration costs were lower for RTX compared to ABA. Discounted total lifetime direct NHS costs were £46,570 and £63,055 for the RTX and ABA groups, respectively. RTX generated a discounted cost saving of £16,485 per patient due to reduced drug acquisition and administration costs. Total QALYs were estimated as 3.879 and 3.812 for RTX and ABA, respectively.
The model predicted that RTX dominated ABA for RA patients who have failed one previous TNF inhibitor therapy, with higher estimated QALYs and lower NHS costs.
Compared to MTX, ABA treatment results in 1.6 additional QALYs at an additional cost of £40,371, giving an ICER of £25,395/QALY, a value in line with other biologic treatments recommended for use in the UK.
Compared to MTX, ABA is a cost-effective treatment.