Systematic Review of Economic Evaluations of Cycling Versus Swapping Medications in Patients With Rheumatoid Arthritis After Failure to Respond to Tumor Necrosis Factor Inhibitors

Abstract

Objective To systematically review the modeling approaches and quality of economic analyses comparing cycling tumor necrosis factor inhibitors (TNFi) to swapping to a therapy with a different mode of action in patients with rheumatoid arthritis whose initial TNFi failed. Methods We searched electronic databases, gray literature, and references of included publications until July 2017. Two reviewers independently screened citations. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Data regarding modeling methodology were extracted. Results We included 7 articles comprising 19 comparisons. Three studies scored ≥16 of 24 on the CHEERS checklist. Most models used a lifetime horizon, took a payer perspective, employed a 6‐month cycle length, and measured treatment efficacy in terms of the American College of Rheumatology improvement criteria. We noted possible sources of bias in terms of transparency and study sponsorship. In the cost‐utility comparisons, the median incremental cost‐effectiveness ratio was US $70,332 per quality‐adjusted life‐year for swapping versus cycling strategies. Rituximab was more effective and less expensive than TNFi in 7 of 11 comparisons. Abatacept (intravenous) compared to TNFi was less cost‐effective than rituximab. Common influential parameters in sensitivity analyses were the rituximab dosing schedule, assumptions regarding disease progression, and the estimation of utilities. Conclusion Differences in the design, key assumptions, and model structure chosen had a major impact on the individual study conclusions. Despite the existence of multiple reporting standards, there continues to be a need for more uniformity in the methodology reported in economic evaluations of cycling versus swapping strategies after TNFi in patients with rheumatoid arthritis.

Managing inadequate response to initial anti-TNF therapy in rheumatoid arthritis: optimising treatment outcomes

“…82 , 83 Anti-TNFs were reported to have the lowest costs and highest quality-adjusted life-year (QALYs) ( vs other biologics), and were deemed to be the most cost-effective treatment option in RA. 83 Using a US-based administrative-claims database, Karpes Matusevich et al 19 reported that swapping to non-anti-TNF targeted agents was cost-effective at the US$100,000 per QALY threshold following failure of anti-TNF treatment in patients with RA, although differences in the design, key assumptions, and model structure chosen had a major impact on the individual study conclusions. This study highlighted the need for further studies to evaluate cost-effectiveness with switching choices other than rituximab or IV abatacept, to better reflect current clinical practices, of longer-term studies on the progression of RA, of RA costs over time and for greater standardisation and transparency in the reporting of economic evaluation studies.…”

“…1 The European League Against Rheumatism (EULAR) recommends a treat-totarget strategy aiming for sustained clinical remission (or low disease activity) recommending 1 Historically, anti-TNFs have accounted for the majority of first-line biological therapies for RA, which may have increased further due to their increased cost-effectiveness following the introduction of biosimilars. 17,18 However, 30-40% of patients with RA discontinue anti-TNFs due to primary IR (lack of response identified following initial dosing), secondary IR (reduction in initial response over time) or intolerance; 1,19,20 each situation necessitates a change in treatment regimen.…”