OBJECTIVES:

The study aimed to determine the cost-effectiveness of initiating tofacitinib treatment in patients with moderate to severe rheumatoid arthritis (RA) previously treated with methotrexate (MTX) and showing inadequate response to a second-line therapy with any anti-tumor-necrosis-factor Alpha (TNF-IR population), in comparison to alternative treatment sequences excluding tofacitinib.

METHODS:

A patient-level microsimulation model was customized to estimate from the Spanish National Health system, the lifetime costs and quality-adjusted life-years (QALY) for sequences of therapies initiating with tofacitinib (5mg BID) followed by biological therapies versus sequences of biological treatments only. The sequences were selected by a panel of experts based on clinical practice. MTX concomitant treatment was considered along all the therapies in the treatment sequences.

The model’ parameters comprised demographic (age, weight), and clinical inputs (initial Health Assessment Questionnaire [HAQ] score and clinical response to short and long treatment). Efficacy was measured by means of HAQ score changes using mixed-treatment-comparisons (for first 6 months) and data from long-term extension trials (for later periods).

Serious adverse event (SAE) information derived from literature.

The total cost estimation included: drugs acquisition (public ex-factory prices with mandatory deduction or reference prices) and parenteral administration, disease progression and SAE management. Local unitary costs (€, 2018) were applied.

RESULTS:

Initial treatment with Tofacitinib+MTX followed by Abatacept_sc+MTX->Rituximab+MTX->Certolizumab+MTX provided greater QALYs (0.16) than the following alternative sequence: Tocilizumab_sc+MTX->Abatacept_sc+MTX->Rituximab+MTX->Certolizumab+MTX

The tofacitinib-containing sequence resulted in lower total costs (-€34,475 incremental cost compared the alternative sequence) being a dominant option.

Alternative sequences were also compared: Tofactinib+MTX->Tocilizumab_sc+MTX->Abatacept_sc+MTX->Rituximab+MTX versus Tocilizumab_sc+MTX->Abatacept_sc+MTX->Rituximab+MTX->Certolizumab+MTX, where tofacitinib-containing sequences resulted less effective (-0.06 incremental QALY) but remained a cost-saving option (-€31.158 incremental cost)

CONCLUSIONS:

Positioning of tofacitinib as initial third-line therapy followed by other biologicals, resulted a cost-saving strategy compared to the continuation of treatment with biologicals only, in moderate to severe RA TNF-IR patients, in Spain.