The Economic Implications of TNF-α Inhibitors in the Treatment of Psoriatic Arthritis

Nick Bansback1, Roberta Ara1, Nichol Barkham2, Alan Brennan1, Alexander Fraser2,Paul Emery2
[1] Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, S1 4DA, UK [2] Academic Unit of Musculoskeletal Disease, University of Leeds, LS3 9NZ, UK
Contact: n.j.bansback@sheffield.ac.uk http://www.sheffield.ac.uk/scharr/sections/heds The University of Sheffield

Introduction Methods Results

The most common method for assessing the cost-effectiveness Estimate health state utility from HAQ Disability index Ratio of incremental cost and incremental QALYs decreases over time
(CE) of health care interventions is to assess their incremental OLS regression used to predict population mean not individual patient
cost per Quality Adjusted Life Years (QALY)   6 Months 1 Year 5 Years 10 Years

Efficacy of TNF-α inhibitors is well understood but not in terms 1 Etanercept Comparator Etanercept Comparator Etanercept Comparator Etanercept Comparator
of improvement in health state utility used to quantify QALY 0.8 Total Costs £ 4,897 £1,901 £ 8,974 £3,675 £33,103 £15,813 £51,122 £28,010
calculations 0.6 Incremental Cost 2,996 5,299 17,290 23,112
Decision makers require calculations for long term implications 0.4 QALY 0.29 0.24 0.63 0.52 2.71 2.24 4.49 3.67

EQ-5D utility
of funding. Only short term data available 0.2 Incremental QALY 0.04 0.10 0.46 0.82
EQ-5D
Economic models are used to synthesise data to inform utility 0
Incremental Cost per QALY £66,589 £52,076 £37,398 £28,189
decision makers such as NICE on cost effectiveness decisions -0.2

This work uses patient level data from trial of etanercept [Mease
et al, 2004] along with the literature to estimate long term CE
-0.4
Uncertainty in estimates increases over 10 (results below of a probabilistic sensitivity analysis)
-0.6 £50,000
0.0 0.5 1.0 1.5 2.0 2.5 3.0

HAQ-DI 6 Month H orizon

HAQ- DI £45,000 £ 30 ,0 0 0 pe r Q ALY g aine d
Patient Pathway 2 Year Horizon

Predict long term progression

£40,000
10 Year Horizon
Patients assumed to have failed previous DMARDs and NSAIDs £2 0,0 00 per QA LY ga ined
OLS multivariate regression used to predict initial HAQ improvement £35,000

ost
IncrementalCcost
Estimate Std. Error t value Pr(>|t|) £30,000
HAQ at 4 weeks
Patients with Active disease despite treatment (Intercept) -0.102 0.113 -0.907 0.365

Incremental
£25,000
with Disease Modifying Antirheumatic Drugs Baseline HAQ 0.781 0.039 19.799 < 2e-16
(DMARDs). Age 0.006 0.002 2.573 0.011 £20,000
Etanercept -0.200 0.050 -3.968 0.000
PsARC response at 4 week -0.121 0.052 -2.342 0.020 £15,000
Multiple R-Squared: 0.6891, Adjusted R-squared: 0.6828
HAQ at 12 weeks £10,000 £1 0,0 00 per QA LY ga ined
(Intercept) 0.053 0.108 0.495 0.621
Model starts
Methotrexate -0.122 0.071 -1.724 0.086 £5,000
Baseline HAQ 0.853 0.075 11.389 < 2e-16
Duration of PsA 0.007 0.003 2.014 0.045 £0
Polyarthritis 0.147 0.076 1.934 0.055 -0.3 -0.2 -0.1 0 0.1 0.2 0.3 0.4 0. 5 0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2

Etanercept -0.295 0.060 -4.914 0.000 -£5,000

PsARC response at 4 week -0.180 0.080 -2.245 0.026 In c r em en tal e ffe ctiv e n es s
PsARC response at 12 week -0.021 0.123 -0.170 0.865 -£10,000

Cyclosporin + Etanercept 25mg Mtx : PsARC response at 4 week 0.163 0.112 1.448 0.149
Methotrexate twice weekly Bs HAQ: PsARC rspns 12 week -0.211 0.094 -2.238 0.026
Multiple R-Squared: 0.6504, Adjusted R-squared: 0.6342

Patients HAQ/ utility is assumed ‘rebound’ by same amount as initial Discussion

$ #/$
gain instantaneously after withdrawal Limitations
Best Cyclosporin + Long term progression taken from estimates from literature [Sokoll, Efficacy in terms of improvement of psoriasis element not captured – further studies looking at health state
standard care Methotrexate 2001]
1

Etanercept
utility and its changes in terms of HAQ and PASI required
0.8
Comparator Evidence base on costs and long term progression in PsA is small – requires further investigation
$ particularly on how level HAQ and PASI effect hospitalisation and other costs
Health Utility

0.6
Long term evidence on TNF-α inhibitors is limited – registries and observational trials required to analyse
Best long term efficacy and safety
standard care 0.4

Conclusions
0.2 Etanercept appears to be a cost effective intervention for patients who have attempted previous DMARDs.
0
Using a probabilistic sensitivity analysis, results suggest that one is 58% certain etanercept is cost effective
#
Inadequate response to treatment after 3 months based on PsARC response [BSR
Inadequate response
Years 0 1 2 3 4 5 6 7 8 9 10 at the £30,000 per QALY threshold used by NICE
guidelines, 2004] to treatment Cumulative Etanercept 0 0.63 1.21 1.75 2.25 2.71 3.11 3.49 3.84 4.16 4.49
QALYs Comparator 0 0.52 1.01 1.46 1.87 2.24 2.59 2.90 3.19 3.45 3.67 Univariate sensitivity analysis (not shown) demonstrates that baseline HAQ, whether non responders are
$ Withdrawal
Withdrawaldue
duetoto
toxicity
toxicity loss or of efficacy % remaining on etanercept 100.0 59.4 50.5 2.5 35.5 30.3 24.0 20.1 17.3 15.4 13.7 withdrawn, and HAQ progression are most sensitive variables
% alive 100.0 99.8 99.6 99.4 99.2 98.9 98.6 98.3 98.0 97.6 97.2

Continued response to treatment References

Continued response Mease P. Etanercept treatment of psoriatic arthritis: Safety, efficacy, and effect on disease progression.
Estimate Costs Arthritis & Rheumatism 2004;50(7)2264-2272 Supported by consultancy grant from Wyeth, UK
Sokoll KB. Comparison of disability and quality of life in rheumatoid and psoriatic arthritis. J Rheumatol Presented at ACR Annual Conference, San Antonio, 2004
Drug and monitoring costs included 2001;28:1842–1846.
BSR Guidelines for biologics in PsA. www.rheumatology.org.uk
Hospitalisation costs saved due to improving HAQ incorporated