OBJECTIVES: To examine the cost-effectiveness of apremilast versus methotrexate over a lifetime horizon for systemic-naïve patients with moderate-to-severe plaque psoriasis from a societal US perspective.

METHODS: A cost-utility analysis was performed to compare two strategies: initiating treatment with apremilast versus methotrexate, with possible switching to etanercept in both arms. We created a hybrid model using a decision tree simulation over the first year, followed by a Markov model over a lifetime horizon. The modeled population was comprised of systemic-naïve patients reflected in placebo-controlled clinical trials. Input parameters were derived from these trials and from previously published comparative effectiveness trials, preference-mapping studies, and cohort studies. The main outcomes of interest were incremental costs, incremental quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). A one-way sensitivity analysis was performed on all relevant parameters.

RESULTS: The base-case scenario showed that initiating treatment with apremilast versus methotrexate resulted in an ICER of -$104,392 per QALY over the patient’s lifetime; that is, apremilast was a dominated strategy (both more costly and less effective). The results from the sensitivity analysis suggested that utilities were the main drivers of the model.

CONCLUSIONS: The analysis showed that initiating treatment with methotrexate was a dominant strategy compared to initiating treatment with apremilast in systemic-naïve patients. Although it is not cost-effective to initiate treatment with apremilast, we may consider other roles it can play in therapy, including as adjunct therapy, as last-line for those who did not respond to other oral systemic therapies, or for those with comorbid psoriatic arthritis. Head-to-head clinical trials assessing comparative effectiveness of apremilast with other oral systemic agents should be conducted to provide stakeholders with a better understanding of the comparative efficacy and role of apremilast in psoriasis therapy.