OBJECTIVES: To evaluate cost-effectiveness of upadacitinib (targeted synthetic-disease modifying anti-rheumatic drug [ts-DMARD]) as 1^st-line treatment (1L) versus current treatment pathway among patients with rheumatoid arthritis (RA) in Kingdom of Saudi Arabia (KSA), who had inadequate response to prior conventional-DMARDs and/or biologic‑DMARDs.

METHODS: This excel-based model included patients with moderate-RA (Disease activity score [DAS28]: >3.2 to ≤5.1) and severe-RA (DAS28>5.1). Cost-effectiveness of current treatment pathway (1L: adalimumab-originator/biosimilar, 2L: other biologic-DMARDs/tofacitinib) was compared against new treatment pathway with two scenarios (1L: upadacitinib, 2L: adalimumab‑biosimilar [scenario-1]/adalimumab-originator [scenario-2]) for 10-year time‑horizon. Societal perspective including indirect costs (productivity loss) was adopted with 3.0% discounting rate. Model outcomes included total direct-costs (drug-acqusition/drug-administration/monitoring/hospitalization/surgical-cost) and indirect-costs, quality-adjusted life-years (QALYs), hospitalization days, number of orthopaedic surgeries, and incremental cost-utility ratio (ICUR) per QALY. One-way and probabilistic-sensitivity analysis was performed on the costs/clinical/utility/other literature-based variables.

RESULTS: With the current pathway, the estimated total societal-costs for 100 RA patients for 10‑year period are SAR 50,450,354 (moderate-RA) and SAR 50,013,945 (severe-RA). New pathway with scenario-1 shows that in patients with moderate- and severe-RA, upadacitinib leads to higher QALYs gain (+8.99 and +15.63) at lower societal-cost (cost difference: -SAR 2,023,522 and -SAR 3,373,029). Thus, as 1L, upadacitinib projects ‘dominant’ ICUR per QALY over current pathway. Moreover, in new pathway with scenario-2, upadacitinib also projects ‘dominant’ ICUR per QALY for patient with severe-RA (QALY gain: +15.63, cost difference: -SAR 164,536). However, for moderate-RA, it is associated with additional cost of SAR 1,255,696 for improved QALY (+8.99) over current pathway (ICUR per QALY: SAR 139,742). Both scenarios project reduced hospitalization days (scenario-1: -14.83, scenario-2: -11.41) and number of orthopaedic surgeries (scenario-1: -8.36, scenario-2: -6.54) with new pathway for moderate- to severe-RA patients.

CONCLUSIONS: Upadacitinib as 1L in moderate- to severe-RA will bring significant reduction in healthcare-resources utilization in KSA, majorly due to reduced cost of drug‑administration/monitoring/hospitalization/surgical-cost/indirect-costs.