Presentation (CTI)

OBJECTIVES: Rheumatoid arthritis (RA) treatment guidelines in Portugal specify a sequence from conventional synthetic to biological and targeted disease-modifying anti-rheumatic drugs, with the latter associated with substantial costs. Subcutaneous methotrexate as a first-line therapy, or after failing first-line oral methotrexate, has been shown in cost-utility analyses (CUAs) to reduce total costs by delaying, or avoiding, biologic treatment. This study conducted a similar analysis for Portugal.
METHODS: A lifetime CUA was performed from the Portuguese National Health Service’s perspective, adapting a published model. Successive lines of therapy were modelled per Portuguese guidance. The base case compared first-line subcutaneous methotrexate with current practice; a scenario analysis examined subcutaneous methotrexate use after first-line oral methotrexate failure. Clinical, utility, and cost inputs were drawn from the literature and expert opinion. Value for money was expressed as net monetary benefit (NMB), at a willingness-to-pay threshold of €50,000 per quality-adjusted life-year (QALY). Sensitivity and scenario analyses were performed to assess the robustness of results.
RESULTS: Relative to current practice, first-line subcutaneous methotrexate was projected to generate 0.25 life-years and 0.55 QALYs and reduce costs by €11,108 (NMB: €38,821). Second-line subcutaneous methotrexate yielded gains of 0.54 life-years and 1.19 QALYs, with cost savings of €25,892 (NMB: €85,485) relative to current practice. In both analyses, subcutaneous methotrexate was dominant, i.e., improved effectiveness and reduced costs. Health gains were attributable to more time spent on active treatment, better disease control, and consequently improved health-related quality of life and lower mortality risk. Cost savings arose from fewer hospitalizations and delayed/avoided biologic therapy, more than offsetting subcutaneous methotrexate acquisition costs. Sensitivity and scenario analyses, including alternative biologic sequences, corroborated base case findings.
CONCLUSIONS: Subcutaneous methotrexate represented good value for money, relative to current practice, in RA management in Portugal. These results support broader adoption of subcutaneous methotrexate in Portuguese clinical practice.