OBJECTIVES

Ustekinumab was recently approved by the FDA for the treatment of Crohn’s disease (CD). This model evaluates the cost-effectiveness of ustekinumab compared with infliximab and adalimumab for the treatment of moderate-severe CD in patients that have failed conventional therapy but are naïve to tumor necrosis factor antagonists.

METHODS

A decision tree simulated biologic induction and a Markov model simulated biologic and conventional therapy (CT) maintenance. Cycle length was 2 weeks with a discounted 5-year time horizon and a US societal perspective in the base case; the payer perspective is also reported. Transition probabilities, direct costs, indirect costs, and utilities were obtained or derived from literature. Incremental net monetary benefits (NMBs) are reported for a $150,000 willingness to pay (WTP) threshold per quality-adjusted life-year (QALY) in the base case.

RESULTS

Infliximab dominates both adalimumab and ustekinumab with incremental NMBs of $9,943 and $29,798 respectively in the base case. All biologics yield similar QALYs while costs vary significantly. The payer perspective, alternate time horizons, and scenario analyses consistently show infliximab dominance. One-way, threshold, and probabilistic sensitivity analyses confirm the robustness of results with respect to all parameters. Threshold sensitivity analysis indicates that lower biologic induction efficacy yields higher treatment value. This result is explained by CT maintenance treatment value: patients who fail to respond during biologic induction avoid high biologic maintenance costs and still experience significant QALY gains from CT maintenance. Threshold sensitivity analysis also indicates that adalimumab has highest relative treatment value when average hourly compensation is more than $621 per hour.

CONCLUSIONS

For moderate-severe CD, infliximab yields slightly more QALYs at a significantly lower cost compared to both adalimumab and ustekinumab. Drug acquisition costs are the only parameters that could alter relative treatment value but would have to be varied by at least 50% to do so.