Added Biologic for RA Found Not Cost-Effective in Swedish Study

Eriksson JK, Karlsson JA, Bratt J, et al., Cost-effectiveness of infliximab versus conventional combination treatment in methotrexate-refractory early rheumatoid arthritis: 2-year results of the register-enriched randomised controlled SWEFOT trial. Ann Rheum Dis. (2014) Apr 15. doi: 10.1136/annrheumdis-2013-205060. [Epub ahead of print]  

An analysis from Sweden, where access to nationalized healthcare registries enables robust estimates of costs and benefits, has matched a biologic versus conventional DMARDs head-to-head, and deemed the cost of the biologic not acceptable by societal measures.

Using productivity and quality of life as outcomes, adding the TNF inhibitor infliximab proved far less cost-effective than "triple therapy" (adding the conventional DMARDs sulfasalazine and hydroxychloroquine) to treat early rheumatoid arthritis refractory to methotrexate (MTX), according to results from a major clinical trial. This extends earlier findings from the same trial that a beneficial clinical effect of the biologic is not sustained in the long term.

Adding infliximab to MTX for 21months in Sweden cost €27,487 (in 2011 Euros) or about $38,000 in current US dollars, compared to €10,364 (2011 Euros) or less than $14,500 in today’s dollars for adding sulfasalazine and hydroxychloroquine -- with no difference in productivity losses or quality-adjusted life years (QALYs).

What's your preferred practice in this clinical situation? Add your voice to the first edition of Rheumatology Network's new Practice Poll about unresolved issues in rheumatology, created by Editorial Board member Stephen A. Paget MD:

RN Practice Poll #1: Your Strategy After MTX Fails in RA

The total costs included not only antirheumatic drugs but also inpatient care (including surgery), non-primary outpatient care (including day surgery), work loss due to sick leave, and disability pensions, estimated during the 21 months of follow-up.  Among factors adding to the cost of the infliximab was that it was administered in the hospital, and that patients taking it saw their rheumatologists more often.

The trial involved patients previously enrolled in the SWEdish FarmacOTherapy (SWEFOT) trial who had not achieved low disease activity with MTX monotherapy. The 487 patients with early RA resistant to MTX monotherapy, recruited from 15 rheumatology centers in Sweden, were assigned randomly to MTX plus infliximab (n=128) or triple DMARD therapy (n=130), and followed at 3-month intervals.

Previous results from SWEFOT, published in 2012, found that the TNF-inhibitor plus MTX produced a better treatment response initially (at 9 months), but the difference in these outcomes over triple therapy was not sustained to 15 or 21 months.

Further results reported in 2013 found better radiographic outcomes and treatment adherence among the TNF inhibitor group, but no differences in quality of life or improvements in work loss.

Compared to the conventional therapy, adding infliximab was not found to be cost effective at “willingness-to-pay” levels generally considered acceptable, or $50, 000 to $100, 000 per QALY. However, the authors add, it can "only be speculated" whether observed differences in the radiographic results and adherence might affect physical function or pain in ways that would alter the economic conclusions in the long term.