OBJECTIVES: To assess the cost-effectiveness of placing apremilast before biologics in adult patients with active psoriatic arthritis, who have failed to respond to or are intolerant of conventional disease-modifying antirheumatic drugs from a Greek payer perspective.

METHODS: A 40-year Markov transition model with monthly cycle duration was used. Treatment strategies consisted of apremilast prior to a biologic drug sequence compared with a biologic-only sequence. Sequential biologics were etanercept, adalimumab, golimumab and infliximab for both treatment strategies. Patients failing infliximab received best supportive care as last line of treatment. Response to treatment was assessed using the Psoriatic Arthritis Response Criteria (PsARC) at the end of the trial periods, obtained from a meta-analysis. Non-responders moved to the next treatment line. Long-term treatment withdrawal and patients’ adjusted mortality rates were retrieved from the literature and national published sources. Utilities were obtained as a linear function of the Health Assessment Questionnaire (HAQ) and Psoriasis Area and Severity Index (PASI) scores based on a published regression equation. Following a payer perspective, direct costs relating to drug acquisition, administration, monitoring and overall patient management were considered (€, 2017). An annual discount rate of 3.5% was applied for costs and health benefits.

RESULTS: The apremilast sequence before biologics resulted in an incremental cost per quality-adjusted life-year (QALY) gained of €23,242. Specifically, apremilast sequence was associated with 0.35 incremental QALYs compared with the biologic-only sequence (9.62 vs 9.27), at additional costs of €8,218 (€142,887 vs €134,670) over a patient’s lifetime. Results were most sensitive to changes in HAQ score and discount rates. At the defined willingness-to-pay threshold of €34,000, apremilast sequence was estimated to have a 79% probability of being cost-effective.

CONCLUSIONS: Placing apremilast before biologics was found to be a cost-effective strategy for the treatment of active PsA in the Greek healthcare setting.