Cost Utility of Subcutaneous Methotrexate As a Second-Line Treatment for Moderate to Severe Rheumatoid Arthritis in the UK
Author(s)
Matthew Tucker, MSc1, Johannes Pöhlmann, MPH, MSc1, Kristin Grabe-Heyne, PhD2, Annelie Wagner, PhD2, Anja Rasch, PhD2, Mondher Toumi, MSc, PhD, MD3, Muhammad K. Nisar, PhD4, Richard F. Pollock, MA, MSc1.
1Covalence Research Ltd, Harpenden, United Kingdom, 2medac GmbH, Wedel, Germany, 3University Aix-Marseille, Marseille, France, 4Luton & Dunstable University Hospital, Luton, United Kingdom.
1Covalence Research Ltd, Harpenden, United Kingdom, 2medac GmbH, Wedel, Germany, 3University Aix-Marseille, Marseille, France, 4Luton & Dunstable University Hospital, Luton, United Kingdom.
OBJECTIVES: Rheumatoid arthritis (RA) is a chronic autoimmune condition characterized by joint inflammation, pain, disability, and long-term joint damage. Oral methotrexate is the standard first-line treatment. Subcutaneous methotrexate has higher bioavailability than oral methotrexate, offers improved efficacy and tolerability, and has been proposed as second-line treatment to delay escalation to biologics. This study evaluates the cost-utility of a treatment pathway including subcutaneous methotrexate following oral methotrexate versus current standard of care in patients with moderate-to-severe RA in the UK.
METHODS: A hybrid decision tree-Markov model simulating RA treatment pathways was developed. The decision tree classifies patients as (non-)responders based on American College of Rheumatology criteria. Responders continue first-line therapy; non-responders transition to second-line treatment. In the Markov model, health states are defined by treatment line, with patient entry determined by decision tree outcomes. Transitions represent discontinuation due to inefficacy or toxicity. Patients remain in the model until death or transition to best supportive care (absorbing state with no further treatment options). Health Assessment Questionnaire scores change over time by Markov state, affecting quality of life, mortality, and hospitalisation costs. Costs of resource use, adverse events, and treatment were included.
RESULTS: Over a 30-year time horizon, the treatment pathway including subcutaneous methotrexate as a second-line option was projected to be less costly and more effective versus standard of care (without second-line subcutaneous methotrexate), with £8,278 in total cost savings, 0.14 quality-adjusted life years gained, and a net monetary benefit of £11,020. Cost savings resulted from delaying and reducing initiation of biologics. One-way and probabilistic sensitivity as well as scenario analyses showed dominance across all variations and iterations, including for subcutaneous methotrexate as first-line treatment.
CONCLUSIONS: Including subcutaneous methotrexate as second-line treatment after oral methotrexate in RA represents effective healthcare resource use in the UK, improving patient outcomes while reducing total costs.
METHODS: A hybrid decision tree-Markov model simulating RA treatment pathways was developed. The decision tree classifies patients as (non-)responders based on American College of Rheumatology criteria. Responders continue first-line therapy; non-responders transition to second-line treatment. In the Markov model, health states are defined by treatment line, with patient entry determined by decision tree outcomes. Transitions represent discontinuation due to inefficacy or toxicity. Patients remain in the model until death or transition to best supportive care (absorbing state with no further treatment options). Health Assessment Questionnaire scores change over time by Markov state, affecting quality of life, mortality, and hospitalisation costs. Costs of resource use, adverse events, and treatment were included.
RESULTS: Over a 30-year time horizon, the treatment pathway including subcutaneous methotrexate as a second-line option was projected to be less costly and more effective versus standard of care (without second-line subcutaneous methotrexate), with £8,278 in total cost savings, 0.14 quality-adjusted life years gained, and a net monetary benefit of £11,020. Cost savings resulted from delaying and reducing initiation of biologics. One-way and probabilistic sensitivity as well as scenario analyses showed dominance across all variations and iterations, including for subcutaneous methotrexate as first-line treatment.
CONCLUSIONS: Including subcutaneous methotrexate as second-line treatment after oral methotrexate in RA represents effective healthcare resource use in the UK, improving patient outcomes while reducing total costs.
Conference/Value in Health Info
2025-11, ISPOR Europe 2025, Glasgow, Scotland
Value in Health, Volume 28, Issue S2
Code
EE315
Topic
Economic Evaluation
Disease
Musculoskeletal Disorders (Arthritis, Bone Disorders, Osteoporosis, Other Musculoskeletal)