A cost effectiveness analysis of treatment options for MTX-naive RA

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J Rheumatol 2002 Jun;29(6):1156-65

A cost effectiveness analysis of treatment options for methotrexate-naive

rheumatoid arthritis.

Choi HK, Seeger JD, Kuntz KM.

Department of Medicine, Massachusetts General Hospital, Harvard Medical School,

Boston 02114, USA. HCHOI@...

OBJECTIVE: New treatment options for patients with methotrexate (MTX)-naive

rheumatoid arthritis (RA) have become available. Given wide variability in

efficacy and cost among different treatment options, we sought to determine

their relative cost effectiveness to help guide policy in different cost

constrained settings. METHODS: We performed a cost effectiveness analysis

comparing 5 monotherapy options for patients with MTX-naive RA: (1) etanercept,

(2) leflunomide, (3) MTX (up to 15 mg weekly), (4) sulfasalazine (SSZ), and (5)

no second line agent. A decision analysis model was used with a time horizon of

6 months. We employed 2 measures of effectiveness based on published clinical

trial data: American College of Rheumatology (ACR) 20% response proportion (ACR

20) and a weighted average of proportions achieving ACR 70, ACR 50, and ACR 20

(ACR 70 weighted response, ACR 70WR). Incremental cost effectiveness ratios were

calculated as additional cost per patient achieving either outcome, compared

with the next most expensive option. RESULTS: In both base case analyses

employing ACR 20 and ACR 70WR as effectiveness measures, MTX and SSZ both cost

less and were more effective (i.e., cost saving) than no second line agent.

Leflunomide cost more and was less efficacious than SSZ (dominated) in analyses

using either outcome. The most efficacious option, etanercept, cost US $41,900

per ACR 20 and $40,800 per ACR 70 WR compared with SSZ and MTX, respectively.

When we included only direct costs in analyses, the least expensive

non-dominated option was SSZ with incremental cost effectiveness ratios of US

$900 per ACR 20 and $1500 per ACR 70WR compared with no second line agent.

Overall, relative cost effectiveness between MTX and SSZ was sensitive to

variation in relevant variables in sensitivity analyses. Otherwise, our

extensive sensitivity analyses did not substantially affect the base case

results. CONCLUSION: MTX is cost effective (cost saving vs the no second line

agent option) for MTX-naive RA in achieving ACR 20 or ACR 70WR over a 6 month

period. Based on available data, the relative cost effectiveness between SSZ and

MTX cannot be determined with reasonable certainty and SSZ therapy appears to be

as cost effective as MTX (cost saving) in achieving ACR outcomes over a 6 month

period. The most efficacious option, etanercept, incurs much higher incremental

costs per ACR 20 or ACR 70WR than other options analyzed. Whether etanercept

compared with MTX is cost effective depends on whether > $40,000 per ACR 20 or

ACR 70WR over a 6 month period is considered acceptable.

PMID: 12064828