Abstract & Commentary
Synopsis: Results of a cost-effectiveness study comparing 5 monotherapy treatments for rheumatoid arthritis: methotrexate, leflunomide, etanercept, sulfasalazine, and no therapy.
Source: Choi HK, et al. J Rheumatol. 2002;29:1156-1165.
This study evaluated the cost effectiveness of 5 monotherapy options for treating rheumatoid arthritis (RA) in methotrexate-naïve patients. Previously published data were used to create a decision analysis comparing cost and effectiveness for each treatment regimen. For each treatment option, 5 factors were used to determine which option was the most cost effective: 1) probability of treatment success; 2) direct cost of therapy (administering and monitoring therapy); 3) indirect costs of therapy (lost productivity due to disease morbidity); 4) probability of side effects; and 5) expected cost of side effects. For each treatment option, Choi and colleagues used past studies to estimate the cost of achieving a 20%, 50%, or 70% treatment response (as defined by the American College of Rheumatology [ACR] response criteria).
The most cost-effective drug was methotrexate, costing $10,926 in total costs per 6 months. Choi et al also performed a sensitivity analysis: varying each variable to determine if the outcome of the most cost-effective drug would change. With even minor changes in the variables used in the analysis, sulfasalazine was indistinguishable from methotrexate in cost effectiveness.
Leflunomide cost more than methotrexate and sulfasalazine and was not more effective.
Etanercept was the most efficacious therapy, but also the most expensive, costing $16,165 per 6 months.
In order for the additional efficacy of etanercept to be considered cost effective, an incremental improvement of a 20% ACR remission of $40,000 would have to be acceptable.
Comment by Jeff Wiese, MD
The recommended treatment for RA is a disease-modifying agent in addition to symptomatic relief (non-steroidals, steroids). Once-a-week methotrexate has been the treatment standard, but newer agents have been introduced.1 Many of these agents have shown increased efficacy when compared to methotrexate.2-4 This study addresses an important question: Is the expense of these newer agents (both in cost and side effects) worth the additional efficacy?
This study used an extensive sensitivity analysis to determine what is the most cost-efficacious choice for the treatment of RA. While etanercept is more efficacious, it is not more cost-effective than methotrexate unless paying $40,000 per additional ACR 20% response is considered acceptable. Based on the sensitivity analysis, it was impossible to determine whether sulfasalazine or methotrexate was more cost effective.
This study also compares the cost effectiveness of methotrexate vs. no therapy. Because of the significant surgical and medical morbidity of RA, and the expected loss of productivity, using no therapy was less cost effective than early treatment with methotrexate.
The studies used to generate the data for these analyses only included methotrexate-naïve patients. Patients that have been previously exposed to methotrexate without a successful response are less likely to show a response the second time; this would reduce the cost-effectiveness of methotrexate.
Dr. Wiese, Chief of Medicine, Charity, and University Hospitals, Associate Chairman of Medicine, Tulane Health Sciences Center, is Associate Editor of Internal Medicine Alert.
References
1. Kremer JM. Rheum Dis Clin North Am. 1998;24:651-658.
2. Strand V, et al. Arch Intern Med. 1999;159:2542-2550.
3. Weinblatt ME, et al. N Engl J Med. 1999;340:253-259.
4. Moreland LW, et al. Ann Intern Med. 1999;130:478-486.
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