OBJECTIVES: Many patients with rheumatoid arthritis (RA) fail to respond adequately to first-line therapy with conventional disease-modifying antirheumatic drugs (cDMARDs). Biologic disease-modifying antirheumatic drugs (bDMARDs) have improved outcomes, and multiple guidelines National Institute for Health and Care Excellence (NICE) govern their prescription in England and Wales. The study objective was to estimate the cost-effectiveness of treatment sequences of alternative bDMARDs versus cDMARDs in patients who have failed to respond to at least two cDMARDs.

METHODS: A discrete event simulation model was used to explore the cost-effectiveness of bDMARDs in combination with methotrexate versus cDMARDs. Populations of interest were patients with severe and moderate to severe RA who failed to respond to at least two cDMARDs including methotrexate (cDMARD-IR). In the severe population, eight alternative bDMARD strategies and one cDMARD strategy were considered. In the moderate population, a single bDMARD strategy was compared against a cDMARD strategy. Strategies evaluated differed by the therapy with which the strategy began (a bDMARD or cDMARDs) and thereafter were based on current NICE guidance. The perspective was that of the UK National Health Service and Personal Social Services. The main outcome was the incremental cost-effectiveness ratio (ICER, expressed as cost per quality-adjusted life years).

RESULTS: In a severe population, etanercept resulted in an ICER of £22,243 versus a cDMARD strategy (7 strategies strictly or extendedly dominated). In a moderate to severe population the ICER for the etanercept strategy was £23,352 versus the cDMARD strategy. In probabilistic sensitivity analysis, the etanercept strategy had the highest probability of being cost-effective at a threshold of £30,000. CONCLUSIONS: Based on the results of this analysis, a treatment strategy beginning with etanercept was considered to be the most cost-effective in patients with severe and moderate to severe RA who failed to respond to at least two conventional DMARDs.