Triple therapy versus biologic therapy for Active Rheumatoid Arthritis a cost-effectiveness analysis

Nick Bansback, Ciaran Phibbs, Huiying Sun, James R. O'Dell, Mary Brophy, Edward C. Keystone, Sarah Leatherman, Ted R. Mikuls, Aslam H. Anis, William Ayoub, Gilles Boire, Vivian Bykerk, Andrew Chow, Keith Colburn, David Daikh, John Davis, Hani El-Gabalawy, Jennifer Elliott, Joseph Fanciullo, Samardeep GuptaKeri Hannagan, Raymond Hausch, Erika Holmberg, Amy Joseph, Salahuddin Kazi, Peter Kent, Gail Kerr, Karen Kolba, C. Kent Kwoh, Maren Mahowald, Liam Martin, Thomas Olenginski, Jay Persselin, Mahfooz Peshimam, Lynne Peterson, Pamela Prete, David Pugliese, Virginia Reddy, Andreas Reimold, Jude Rodrigues, H. Ralph Schumacher, J. Carter Thorne, Joanne Valeriano-Marcet, Cynthia Weaver, Ciaran S. Phibbs

Research output: Contribution to journalArticlepeer-review

47 Scopus citations


Background: 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). Objective: To determine the cost-effectiveness of etanercept-methotrexate versus triple therapy as a first-line strategy. Design: 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. Data Sources: The RACAT trial and sources from the literature. Target Population: Patients with active RA despite at least 12 weeks of methotrexate therapy. Time Horizon: 24 weeks and lifetime. Perspective: Societal and Medicare. Intervention: Etanercept-methotrexate first versus triple therapy first. Outcome Measures: Incremental costs, quality-adjusted lifeyears (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. Limitation: Data on the long-term benefit of triple therapy are uncertain. Conclusion: 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.

Original languageEnglish
Pages (from-to)8-16
Number of pages9
JournalAnnals of internal medicine
Issue number1
StatePublished - Jul 4 2017


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