Annals of internal medicine 2017 05 30() doi 10.7326/M16-0713
The RACAT (Rheumatoid Arthritis Comparison of Active Therapies) trial found triple therapy to be noninferior to etanercept-methotrexate in patients with active rheumatoid arthritis (RA).
To determine the cost-effectiveness of etanercept-methotrexate versus triple therapy as a first-line strategy.
A within-trial analysis based on the 353 participants in the RACAT trial and a lifetime analysis that extrapolated costs and outcomes by using a decision analytic cohort model.
The RACAT trial and sources from the literature.
Patients with active RA despite at least 12 weeks of methotrexate therapy.
24 weeks and lifetime.
Societal and Medicare.
Etanercept-methotrexate first versus triple therapy first.
Incremental costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs).
Results of Base-Case Analysis
The within-trial analysis found that etanercept-methotrexate as first-line therapy provided marginally more QALYs but accumulated substantially higher drug costs. Differences in other costs between strategies were negligible. The ICERs for first-line etanercept-methotrexate and triple therapy were $2.7 million per QALY and $0.98 million per QALY over 24 and 48 weeks, respectively. The lifetime analysis suggested that first-line etanercept-methotrexate would result in 0.15 additional lifetime QALY, but this gain would cost an incremental $77 290, leading to an ICER of $521 520 per QALY per patient.
Results of Sensitivity Analysis
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, even under optimistic assumptions.
Data on the long-term benefit of triple therapy are uncertain.
Initiating biologic therapy without trying triple therapy first increases costs while providing minimal incremental benefit.
Primary Funding Source
The Cooperative Studies Program, Department of Veterans Affairs Office of Research and Development, Canadian Institutes for Health Research, and an interagency agreement with the National Institutes of Health-American Recovery and Reinvestment Act.