Treatment Sequencing After Failure of the First Biologic in Cost-Effectiveness Models of Psoriasis: A Systematic Review of Published Models and Clinical Practice Guidelines

Abstract

ObjectivesTo analyse the treatment sequencing assumptions after failure on a first-line biologic in cost-effectiveness models of treatment of moderate to severe plaque psoriasis, and to compare them with the most recent treatment guidelines.MethodsA systematic search of MEDLINE, Embase, EconLit and the Cochrane Library databases used free text and Medical Subject Headings terms including psoriasis, biologic therapies indicated for psoriasis, and all types of economic evaluations. Two researchers performed 2-level abstract screening for articles meeting pre-specified inclusion criteria. Assumptions about treatment pathways after first-line biologic failure in the cost-effectiveness models were analysed. A second systematic search was performed for psoriasis clinical practice guidelines. Sequence assumptions were compared with treatment guideline recommendations.ResultsOf 25 cost-effectiveness modelling studies identified, ten estimated the incremental cost per responder; time horizons varied (12 weeks–18 months) and treatment sequencing was not considered. In 15 studies where treatment sequencing was considered, with time horizons up to 10 years, five studies included only a switch to nonsystemic therapy or best supportive care after first-line biologic failure. Another five of the 15 treatment-pathway studies were available only as abstracts with no details of the sequence assumptions. In five of the 15 studies, first-line biologic failure was followed by second-line biologic monotherapy, one of the recommendations in current treatment guidelines. In only one of these five studies was the efficacy of the second-line biologic adjusted downwards, compared with first-line treatment. Only one of these studies considered dose titration with a first-line biologic and none combination therapy (biologic plus methotrexate or phototherapy) after first-line biologic failure, as recommended in some treatment guidelines.ConclusionsCost-effectiveness models of first-line biologics for moderate to severe plaque psoriasis either do not include subsequent treatment regimens or include only some of the regimens recommended in current treatment guidelines. Results may be sensitive to assumptions about treatment sequencing and the choice and efficacy of subsequent treatment regimens.Electronic supplementary materialThe online version of this article (doi:10.1007/s40273-014-0130-5) contains supplementary material, which is available to authorized users.

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“…Although a treatment sequence approach is clinically relevant, it is not without limitations. 46 Efficacy data associated with each of the treatment sequences are not readily available in current literature. As a consequence, it would be expected that the cost-effectiveness results would be sensitive to assumptions about treatment sequencing and the choice and efficacy of subsequent treatment regimens.…”

Psoriasis treatment and management - a systematic review of full economic evaluations

“…These factors will have an independent effect on the outcome of psoriasis management and may mediate or modify the impact of health care on the clinical severity of psoriasis. However, most of the evidence reviewed implicitly assumes psoriasis therapies are simple interventions and independent of the service context and treatment sequence they are delivered within . Evidence and methods need to be developed progressively to capture these issues.…”

Systematic Review of Cost-Effectiveness Analyses of Treatments for Psoriasis

“…Although a long time horizon is preferred, information related to the long-term experience with various psoriasis treatments is largely lacking [10,67]. This includes the annual dropout rates from therapy, the 'remission' period assumed between spells of intermittent treatment, the efficacy of subsequent lines of treatment, the cost and incidence of adverse events, and the risk of hospitalization [10,67].…”

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