OBJECTIVES: To assess the cost-effectiveness of placing apremilast before biologics in adult patients with moderate to severe plaque psoriasis, who have failed to respond to, have a contradiction to, or are intolerant to other systemic treatments, from a Greek payer perspective.

METHODS: A 10-year Markov transition model with monthly cycle duration was used. The analysis compared an apremilast-prior-to-biologics drug sequence vs a biologic-only sequence. Sequential biologics were etanercept, adalimumab, ustekinumab and infliximab for both treatment strategies. Patients failing infliximab received best supportive care as last line of treatment. Response to treatment was defined as a 75% reduction in Psoriasis Area and Severity Index (PASI) score 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 all-cause mortality rates were retrieved from the literature and national published databases, respectively. Utility gains by PASI response were estimated using a published regression equation. Following a payer perspective, direct costs pertaining to drug acquisition, administration, and monitoring were considered (€, 2017). An annual discount rate of 3.5% was applied for both cost and health outcomes.

RESULTS: Placing apremilast before biologics was found to be a dominant strategy (less costly and more effective). The apremilast-prior-to-biologics drug sequence was estimated to generate 0.01 additional quality-adjusted life-years (QALYs), compared with the biologic-only sequence (6.74 vs 6.73) and cost-savings of €778 (€75,582 vs €76,360), respectively. One-way sensitivity analysis confirmed apremilast sequence’s cost-effective profile. At the defined willingness-to-pay threshold of €34,000 per QALY gained, probabilistic sensitivity analysis showed that the apremilast-prior-to-biologics sequence was estimated to have a 90% probability of being cost-effective relative to the biologic-only sequence.

CONCLUSIONS: Placing apremilast before biologics was found to be a dominant strategy for the treatment of moderate to severe plaque psoriasis in the Greek healthcare setting.