medwireNews: Initiating biologic treatment following methotrexate failure in patients with active rheumatoid arthritis (RA) increases costs and only provides minimal benefit compared with using triple therapy first, researchers report.
Triple therapy with sulfasalazine, hydroxychloroquine, and methotrexate “is a combination of drugs that has been promoted for more than a decade but currently is used far less than biologics as a first-line treatment after methotrexate failure,” explain Nick Bansback (University of British Columbia, Vancouver, Canada) and study co-authors.
As reported in the Annals of Internal Medicine, the team analyzed data from the RACAT trial and found that patients receiving first-line biologic treatment with etanercept–methotrexate following methotrexate failure accumulated “marginally more” quality-adjusted life years (QALYs) over 24 and 48 weeks than those receiving triple therapy, at 0.358 versus 0.353 QALYs and 0.743 versus 0.726 QALYs, respectively.
However, treatment with etanercept–methotrexate was associated with “substantially higher” costs than triple therapy, with cumulative costs of US$ 11,295 versus $ 343 over the first 24 weeks of treatment, and $ 19,634 versus $ 3680 over 48 weeks.
And in a lifetime analysis model that extrapolated costs and outcomes, the difference in cost between the two regimens increased from $ 19,395 in the first year of treatment to $ 77,290 over 50 years, but first-line etanercept–methotrexate was only associated with 0.1482 additional lifetime QALYs compared with triple therapy.
“Considering a long-term perspective, an initial strategy of etanercept–methotrexate and biologics with similar cost and efficacy is unlikely to be cost-effective compared with using triple therapy first,” say Bansback and colleagues.
Nevertheless, the researchers caution that “the implication of this study is not that biologics should be withheld from patients with RA not completely controlled by methotrexate alone.”
“Rather, the study demonstrates the cost savings that would result from prescribing triple therapy first, before a biologic, for such patients,” they emphasize.
The authors of an accompanying editorial, Elena Losina and Jeffrey Katz, both from Brigham and Women's Hospital in Boston, Massachusetts, USA, agree, noting that “patients who have RA and no contraindications to triple […] therapy should use it instead of biologics as the next regimen if methotrexate alone fails to control symptoms and radiographic progression.”
And the editorialists conclude that “promoting small improvements at any cost […] may further strain our limited resources and limit access to care not only for patients with RA but also for those with other chronic conditions.”
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