OBJECTIVES: Clinical evidences showed that switching to a different mechanism of action in rheumatoid arthritis (RA) patients not responding or intolerant to a first anti-TNFa is effective. Objective of this study was the assessment of the cost-effectiveness profile of different treatment strategies after a first anti-TNFa.

METHODS: The study was conducted through the development of a Markov model in the perspective of the Italian healthcare system with a 3-year time horizon. The effectiveness was measured in terms of days gained in Low Disease Activity (LDA; DAS28-ESR < 3.2) or in remission (DAS28-ESR < 2.6). The model simulated the response to treatments, based on the findings of the Rotation Or Change (ROC) trial, the probability of discontinuation and switch to a 3^rd-line biologic, and transition to death. Time on treatment curves for 2^nd-line biologics derived from published Italian real-word data. Rituximab was assumed as 3^rd-line biologic for all comparators. Costs were estimated based on published sources and Italian prices and tariffs: drugs, co-medications, administration, routine management (linked to disease severity).

RESULTS: The switch to tocilizumab after the failure of a first anti-TNFa was more effective than a second anti-TNFa, in terms of days in remission (224 vs. 114 days) and of days in LDA (345 vs 193 days). The cost-effectiveness ratio with tocilizumab iv was Euro 174/day in remission and Euro 113/day in LDA. With tocilizumab sc the ratio was Euro 181/day in remission and Euro 117/day in LDA. The same ratios for the anti-TNFa treatments ranged from Euro 233 to Euro 320 per day in remission and from Euro 138 to Euro 190 per day in LDA (minimum was infliximab biosimilar; maximum was certolizumab).

CONCLUSIONS: The switch to a different mechanism of action after the failure of a first anti-TNFa is an effective and cost-effective strategy in RA.