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Stevenson M, Archer R, Tosh J, Simpson E, Everson-Hock E, Stevens J, Hernandez-Alava M, Paisley S, Dickinson K, Scott D, Young A, Wailoo A. Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for the treatment of rheumatoid arthritis not previously treated with disease-modifying antirheumatic drugs and after the failure of conventional disease-modifying antirheumatic drugs only: systematic review and economic evaluation. Health Technol Assess 2018; 20:1-610. [PMID: 27140438 DOI: 10.3310/hta20350] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with increasing disability, reduced quality of life and substantial costs (as a result of both intervention acquisition and hospitalisation). The objective was to assess the clinical effectiveness and cost-effectiveness of seven biologic disease-modifying antirheumatic drugs (bDMARDs) compared with each other and conventional disease-modifying antirheumatic drugs (cDMARDs). The decision problem was divided into those patients who were cDMARD naive and those who were cDMARD experienced; whether a patient had severe or moderate to severe disease; and whether or not an individual could tolerate methotrexate (MTX). DATA SOURCES The following databases were searched: MEDLINE from 1948 to July 2013; EMBASE from 1980 to July 2013; Cochrane Database of Systematic Reviews from 1996 to May 2013; Cochrane Central Register of Controlled Trials from 1898 to May 2013; Health Technology Assessment Database from 1995 to May 2013; Database of Abstracts of Reviews of Effects from 1995 to May 2013; Cumulative Index to Nursing and Allied Health Literature from 1982 to April 2013; and TOXLINE from 1840 to July 2013. Studies were eligible for inclusion if they evaluated the impact of a bDMARD used within licensed indications on an outcome of interest compared against an appropriate comparator in one of the stated population subgroups within a randomised controlled trial (RCT). Outcomes of interest included American College of Rheumatology (ACR) scores and European League Against Rheumatism (EULAR) response. Interrogation of Early Rheumatoid Arthritis Study (ERAS) data was undertaken to assess the Health Assessment Questionnaire (HAQ) progression while on cDMARDs. METHODS Network meta-analyses (NMAs) were undertaken for patients who were cDMARD naive and for those who were cDMARD experienced. These were undertaken separately for EULAR and ACR data. Sensitivity analyses were undertaken to explore the impact of including RCTs with a small proportion of bDMARD experienced patients and where MTX exposure was deemed insufficient. A mathematical model was constructed to simulate the experiences of hypothetical patients. The model was based on EULAR response as this is commonly used in clinical practice in England. Observational databases, published literature and NMA results were used to populate the model. The outcome measure was cost per quality-adjusted life-year (QALY) gained. RESULTS Sixty RCTs met the review inclusion criteria for clinical effectiveness, 38 of these trials provided ACR and/or EULAR response data for the NMA. Fourteen additional trials contributed data to sensitivity analyses. There was uncertainty in the relative effectiveness of the interventions. It was not clear whether or not formal ranking of interventions would result in clinically meaningful differences. Results from the analysis of ERAS data indicated that historical assumptions regarding HAQ progression had been pessimistic. The typical incremental cost per QALY of bDMARDs compared with cDMARDs alone for those with severe RA is > £40,000. This increases for those who cannot tolerate MTX (£50,000) and is > £60,000 per QALY when bDMARDs were used prior to cDMARDs. Values for individuals with moderate to severe RA were higher than those with severe RA. Results produced using EULAR and ACR data were similar. The key parameter that affected the results is the assumed HAQ progression while on cDMARDs. When historic assumptions were used typical incremental cost per QALY values fell to £38,000 for those with severe disease who could tolerate MTX. CONCLUSIONS bDMARDs appear to have cost per QALY values greater than the thresholds stated by the National Institute for Health and Care Excellence for interventions to be cost-effective. Future research priorities include: the evaluation of the long-term HAQ trajectory while on cDMARDs; the relationship between HAQ direct medical costs; and whether or not bDMARDs could be stopped once a patient has achieved a stated target (e.g. remission). STUDY REGISTRATION This study is registered as PROSPERO CRD42012003386. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Rachel Archer
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jon Tosh
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Everson-Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Suzy Paisley
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Kath Dickinson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - David Scott
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Adam Young
- Department of Rheumatology, West Hertfordshire Hospitals NHS Trust, Hertfordshire, UK
| | - Allan Wailoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Buckley F, Finckh A, Huizinga TWJ, Dejonckheere F, Jansen JP. Comparative Efficacy of Novel DMARDs as Monotherapy and in Combination with Methotrexate in Rheumatoid Arthritis Patients with Inadequate Response to Conventional DMARDs: A Network Meta-Analysis. J Manag Care Spec Pharm 2015; 21:409-23. [PMID: 25943002 PMCID: PMC10397966 DOI: 10.18553/jmcp.2015.21.5.409] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Given the availability of a number of alternative biologic treatment options and other novel disease-modifying antirheumatic drugs (DMARDs) for the treatment of patients with rheumatoid arthritis (RA), clinicians are faced with an increasingly challenging choice regarding optimal treatment. Biologics are usually combined with traditional DMARDs, primarily methotrexate (MTX), but some biologics and tofacitinib (together referred to in this article as novel DMARDs) have been shown to be efficacious as monotherapy as well. In real-world practice, approximately one-third of RA patients receiving biologics are on monotherapy, primarily because of intolerance of, or noncompliance with, MTX. Limited data, however, are available analyzing the effectiveness of monotherapy compared with combination therapy across novel DMARDs. OBJECTIVE To compare American College of Rheumatology (ACR) responses to approved novel DMARDs used as monotherapy or as combination therapy with methotrexate (MTX) at 24 weeks in RA patients who have shown inadequate response to conventional DMARDs (DMARD-IR). METHODS Through a systematic review of the literature, we identified randomized controlled trials that assessed approved novel DMARDs used as monotherapy or as combination therapy with MTX in DMARD-IR RA patients. Twenty-eight RCTs were identified that evaluated abatacept, anakinra, adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, tocilizumab, or tofacitinib. ACR responses at 24 weeks were extracted and combined by means of Bayesian network meta-analyses. RESULTS With the exception of anakinra plus MTX, which was less efficacious, most novel DMARDs, when used in combination with MTX, demonstrated comparable ACR responses. When novel DMARDs were used as monotherapies, greater ACR20/50/70 responses were observed with tocilizumab than with anti-tumor necrosis factor agents (aTNF) or tofacitinib. Furthermore, ACR20/50/70 responses with tocilizumab plus MTX were similar to those with tocilizumab monotherapy (odds ratio [OR] for the indirect comparison = 1.08, 95% credible interval [CrI] = 0.40-2.84; OR = 1.24, CrI = 0.44-3.61; OR = 0.95, CrI = 0.33-2.72, respectively), whereas greater responses were observed with aTNF plus MTX than with aTNF monotherapy (OR = 2.41, CrI = 0.51-11.61; OR = 2.85, CrI = 0.51-17.67; OR = 1.28, CrI = 0.21-8.42, respectively). Relative efficacy estimates for the indirect comparison of tofacitinib plus MTX with tofacitinib monotherapy were very uncertain. CONCLUSIONS Results suggest that in combination with MTX most of the available novel DMARDs have similar levels of efficacy in DMARD-IR patients. As monotherapy, however, tocilizumab displayed higher ACR responses than aTNF or tofacitinib. ACR responses with tocilizumab plus MTX were similar to those with tocilizumab as monotherapy, whereas aTNF in combination with MTX demonstrated greater ACR responses than aTNF as monotherapy.
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Affiliation(s)
- Felicity Buckley
- Senior Research Associate, Department of HEOR and Strategic Market Access, Mapi, Boston, Massachusetts
| | - Axel Finckh
- Professor, Rheumatology Division, Geneva University Hospital, Geneva, Switzerland
| | - Tom W. J. Huizinga
- Professor, Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Fred Dejonckheere
- International Payer Strategy Leader, Department of Global Pricing and Market Access, F. Hoffmann-La Roche, Basel, Switzerland
| | - Jeroen P. Jansen
- Adjunct Assistant Professor of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
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Rao VU, Pavlov A, Klearman M, Musselman D, Giles JT, Bathon JM, Sattar N, Lee JS. An evaluation of risk factors for major adverse cardiovascular events during tocilizumab therapy. Arthritis Rheumatol 2015; 67:372-80. [PMID: 25332171 DOI: 10.1002/art.38920] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 10/14/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate associations between lipid levels, inflammation, and rheumatoid arthritis (RA) disease activity, at baseline and during treatment, with the risk of major adverse cardiovascular events (MACE) in tocilizumab-treated patients with RA. METHODS In retrospective post hoc analyses, data were pooled for 3,986 adult patients with moderate to severe RA who received ≥1 dose of tocilizumab (4 mg/kg or 8 mg/kg) intravenously every 4 weeks in randomized controlled trials and extension studies. Cox proportional hazards modeling was used to evaluate associations between baseline characteristics and posttreatment changes in laboratory and disease characteristics (week 24) and change in disease activity and laboratory values from baseline to week 24 with the risk of future MACE during extended followup. RESULTS We identified 50 independently adjudicated cases of MACE during 14,683 patient-years of followup (0.34 MACE cases/100 patient-years). At baseline, age, a history of cardiac disorders, the Disease Activity Score in 28 joints (DAS28), and the total cholesterol:high-density lipoprotein cholesterol ratio were independently associated with MACE in multivariable models (P < 0.05 for all). During treatment, a higher DAS28 and higher swollen and tender joint counts at week 24 were associated with future MACE. In separate models, greater reductions in the DAS28 and joint counts from baseline to week 24 were inversely associated with future MACE; changes in lipid parameters were not statistically significantly associated with the risk of MACE. CONCLUSION In this population of patients treated with tocilizumab, an association was observed between the baseline total cholesterol:high-density lipoprotein cholesterol ratio and an increased risk of MACE. The risk of MACE while receiving treatment, however, was associated with control of disease activity but not lipid changes. Larger studies are needed to confirm these findings.
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Smolen JS, Landewé R, Breedveld FC, Buch M, Burmester G, Dougados M, Emery P, Gaujoux-Viala C, Gossec L, Nam J, Ramiro S, Winthrop K, de Wit M, Aletaha D, Betteridge N, Bijlsma JWJ, Boers M, Buttgereit F, Combe B, Cutolo M, Damjanov N, Hazes JMW, Kouloumas M, Kvien TK, Mariette X, Pavelka K, van Riel PLCM, Rubbert-Roth A, Scholte-Voshaar M, Scott DL, Sokka-Isler T, Wong JB, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis 2014; 73:492-509. [PMID: 24161836 PMCID: PMC3933074 DOI: 10.1136/annrheumdis-2013-204573] [Citation(s) in RCA: 1433] [Impact Index Per Article: 143.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 10/05/2013] [Accepted: 10/11/2013] [Indexed: 02/07/2023]
Abstract
In this article, the 2010 European League against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (sDMARDs and bDMARDs, respectively) have been updated. The 2013 update has been developed by an international task force, which based its decisions mostly on evidence from three systematic literature reviews (one each on sDMARDs, including glucocorticoids, bDMARDs and safety aspects of DMARD therapy); treatment strategies were also covered by the searches. The evidence presented was discussed and summarised by the experts in the course of a consensus finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) were determined. Fourteen recommendations were developed (instead of 15 in 2010). Some of the 2010 recommendations were deleted, and others were amended or split. The recommendations cover general aspects, such as attainment of remission or low disease activity using a treat-to-target approach, and the need for shared decision-making between rheumatologists and patients. The more specific items relate to starting DMARD therapy using a conventional sDMARD (csDMARD) strategy in combination with glucocorticoids, followed by the addition of a bDMARD or another csDMARD strategy (after stratification by presence or absence of adverse risk factors) if the treatment target is not reached within 6 months (or improvement not seen at 3 months). Tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, biosimilars), abatacept, tocilizumab and, under certain circumstances, rituximab are essentially considered to have similar efficacy and safety. If the first bDMARD strategy fails, any other bDMARD may be used. The recommendations also address tofacitinib as a targeted sDMARD (tsDMARD), which is recommended, where licensed, after use of at least one bDMARD. Biosimilars are also addressed. These recommendations are intended to inform rheumatologists, patients, national rheumatology societies and other stakeholders about EULAR's most recent consensus on the management of RA with sDMARDs, glucocorticoids and bDMARDs. They are based on evidence and expert opinion and intended to improve outcome in patients with RA.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
- 2nd Department of Medicine, Hietzing Hospital Vienna, Vienna, Austria
| | - Robert Landewé
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Atrium Medical Center, Heerlen, The Netherlands
| | - Ferdinand C Breedveld
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maya Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine, Free University and Humboldt University, Berlin, Germany
- Clinical Immunology Free University and Humboldt University, Berlin, Germany
| | - Maxime Dougados
- Department of Rheumatology B, Cochin Hospital, René Descartes University, Paris, France
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Cécile Gaujoux-Viala
- Department of Rheumatology, Nîmes University Hospital, Montpellier I University, Nimes, France
| | - Laure Gossec
- Rheumatology Department, Paris 06 UPMC University, AP-HP, Pite-Salpetriere Hospital, Paris, France
| | - Jackie Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sofia Ramiro
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Hospital Garcia de Orta, Almada, Portugal
| | - Kevin Winthrop
- Oregon Health and Science University, Portland, Oregon, USA
| | - Maarten de Wit
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Neil Betteridge
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Johannes W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten Boers
- VU University Medical Center, Amsterdam, The Netherlands
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine, Free University and Humboldt University, Berlin, Germany
- Clinical Immunology Free University and Humboldt University, Berlin, Germany
| | - Bernard Combe
- Service d'Immuno-Rhumatologie, Montpellier University, Lapeyronie Hospital, Montpellier, France
| | - Maurizio Cutolo
- Academic Clinical Unit of Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
| | - Nemanja Damjanov
- 2nd Hospital Department, Institute of Rheumatology, University of Belgrade Medical School, Belgrade, Serbia
| | - Johanna M W Hazes
- Department of Rheumatology, Erasmus MC, University Medical Center, Dr Molewaterplein, Rotterdam, The Netherlands
| | - Marios Kouloumas
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Xavier Mariette
- Hopitaux Universitaires Paris Sud, AP-HP, and Université Paris-Sud, Le Kremlin Bicetre, France
| | - Karel Pavelka
- Institute of Rheumatology and Clinic of Rheumatology, Charles University, Prague, Czech Republic
| | - Piet L C M van Riel
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Marieke Scholte-Voshaar
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - David L Scott
- King's College School of Medicine, Weston Education Centre, London, UK
| | | | - John B Wong
- Division of Clinical Decision Making, Informatics and Telemedicine, Tufts University School of Medicine, Boston, Massachusetts, USA
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Takahashi N, Kojima T, Kaneko A, Kida D, Hirano Y, Fujibayashi T, Yabe Y, Takagi H, Oguchi T, Miyake H, Kato T, Fukaya N, Ishikawa H, Hayashi M, Tsuboi S, Kanayama Y, Kato D, Funahashi K, Matsubara H, Hattori Y, Hanabayashi M, Hirabara S, Terabe K, Yoshioka Y, Ishiguro N. Clinical efficacy of abatacept compared to adalimumab and tocilizumab in rheumatoid arthritis patients with high disease activity. Clin Rheumatol 2014; 33:39-47. [PMID: 24057092 PMCID: PMC3890049 DOI: 10.1007/s10067-013-2392-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 09/08/2013] [Indexed: 11/06/2022]
Abstract
Favourable clinical results in rheumatoid arthritis (RA) patients with high disease activity (HDA) are difficult to achieve. This study evaluated the clinical efficacy of abatacept according to baseline disease activity compared to adalimumab and tocilizumab. This study included all patients registered in a Japanese multicenter registry treated with abatacept (n = 214), adalimumab (n = 175), or tocilizumab (n = 143) for 24 weeks. Clinical efficacy of abatacept in patients with HDA (DAS28-CRP > 4.1) and low and moderate disease activity was compared. Clinical efficacy of abatacept, adalimumab, and tocilizumab was compared in patients with HDA at baseline. In patients treated with abatacept, multivariate logistic regression identified HDA at baseline as an independent predictor for achieving low disease activity (LDA; DAS28-CRP < 2.7) [OR 0.26, 95 % CI 0.14-0.50] or remission (DAS28-CRP < 2.3) [OR 0.26, 95 % CI 0.12-0.56] at 24 weeks. In patients with HDA at baseline, logistic regression did not identify treatment with adalimumab or tocilizumab as independent predictors of LDA or remission compared to abatacept. Retention rates based on insufficient efficacy were significantly higher in patients treated with abatacept compared to adalimumab and lower than tocilizumab. Retention rates based on adverse events in patients treated with abatacept were significantly lower compared to tocilizumab. Clinical efficacy of abatacept was affected by baseline disease activity. There were no significant differences between the three different classes of biologics regarding clinical efficacy for treating RA patients with HDA, although definitive conclusions regarding long-term efficacy will require further research.
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Affiliation(s)
- Nobunori Takahashi
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Hospital, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan,
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Kaufmann J, Feist E, Roske AE, Schmidt WA. Monotherapy with tocilizumab or TNF-alpha inhibitors in patients with rheumatoid arthritis: efficacy, treatment satisfaction, and persistence in routine clinical practice. Clin Rheumatol 2013; 32:1347-55. [PMID: 23703358 DOI: 10.1007/s10067-013-2281-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 03/29/2013] [Accepted: 04/19/2013] [Indexed: 01/18/2023]
Abstract
This study aims to investigate the use of biological disease-modifying antirheumatic drugs (bDMARDs) as monotherapy in patients with rheumatoid arthritis (RA) in "real world" clinical settings and to compare tumor necrosis factor (TNF) inhibitors and tocilizumab monotherapy in terms of efficacy and patient and clinician satisfaction with treatment. This study made use of a retrospective, cohort-19 based study including included data from 254 patients (TNF inhibitors n = 128; tocilizumab n = 126) managed in 30 centers throughout Germany. Efficacy of monotherapy and patient and physician overall satisfaction with treatment were assessed at baseline, 3, and 6 months of monotherapy using a range of measures including Disease Activity Score 28 joint (DAS28), swollen joint count (SJC) and tender joint count (TJC), and visual analogue scales (VAS). Between 18 and 41 % of patients treated with bDMARDs received the agent as monotherapy. Intolerance to DMARDs, contraindications for combination therapy, and comorbidities were the most common reasons for introduction of bDMARD monotherapy. Mean DAS28 (erythrocyte sedimentation rate, ESR) was significantly lower at 3 and 6 months following tocilizumab vs. TNF inhibitors (p ≤ 0.001). Joint counts improved from baseline to month 6 in both groups (SJC -5.1 vs. -3.7 and TJC -5.6 vs. -5.1, for tocilizumab and TNF inhibitors, respectively). Patient as well as physician satisfaction (VAS 100 mm scale) was significantly higher for tocilizumab vs. TNF inhibitors (75.3 vs. 66.8; p = 0.001 and 74.9 vs. 67.1, p = 0.003, respectively). Significantly more patients remained on tocilizumab monotherapy vs. TNF-inhibitor monotherapy (89.7 vs. 75.8 %; p < 0.01). Monotherapy with bDMARDs is common in routine clinical practice. Tocilizumab monotherapy appeared to be superior over TNF-inhibitor monotherapy with respect to DAS28 and drug adherence.
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Affiliation(s)
- Jörg Kaufmann
- Praxis Dr. Kaufmann, Am Bahnhof 4, 14974, Ludwigsfelde, Germany.
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The issue of comparators in economic evaluations of biologic response modifiers in rheumatoid arthritis. Best Pract Res Clin Rheumatol 2013; 26:659-76. [PMID: 23218430 DOI: 10.1016/j.berh.2012.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2012] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Over the last decade, a number of biologic response modifiers (BRMs) have emerged and transformed rheumatoid arthritis (RA) management. Due to their relatively high costs, economic evaluations have attempted to determine their place in the RA treatment armamentarium. This article reviews three key areas where changes to the treatment paradigm challenges findings of existing economic evaluations. METHODS We performed a literature search of economic evaluations examining BRMs approved for use in North America for RA. Only economic evaluations that examined relevant direct costs and health outcomes were included. Data were extracted and summarised, then stratified by patient population and comparators. Reported incremental cost-effectiveness ratios (ICERs) were compared across studies. RESULTS It appears that tumour necrosis factor (TNF) alpha inhibitors are less cost effective compared to disease-modifying anti-rheumatic drugs (DMARDs) for first-line treatment. In addition, it appears that treatment with a TNF alpha inhibitor in patients who were refractory to previous DMARD therapies is more cost effective, compared to switching to another DMARD. Finally, after an inadequate response to a TNF alpha inhibitor, it appears that therapy with rituximab is more cost effective than treatment with another TNF alpha inhibitor or abatacept. DISCUSSION It is important to acknowledge that cost effectiveness depends on which comparators are included in the analyses and the evidence for the comparators. The most typical comparator in the studies was traditional DMARDs, mainly methotrexate. However, as more BRMs come into the market and new clinical evidences emerge on the comparative effectiveness of BRMs, new economic evaluations will need to incorporate this information such that reimbursement decisions can be fully informed regarding relative value.
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Macchioni P, Boiardi L, Catanoso M, Pulsatelli L, Pipitone N, Meliconi R, Salvarani C. Tocilizumab for polymyalgia rheumatica: report of two cases and review of the literature. Semin Arthritis Rheum 2013; 43:113-8. [PMID: 23433960 DOI: 10.1016/j.semarthrit.2013.01.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 01/07/2013] [Accepted: 01/10/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Glucocorticoids (GC) are the mainstay of treatment of polymyalgia rheumatica (PMR). However GC-related adverse events occur frequently, particularly in patients with relapsing disease. Several studies have demonstrated that IL-6 is a key player in the pathogenesis of PMR. OBJECTIVES To report 2 patients with PMR treated with the anti-IL-6 receptor monoclonal antibody tocilizumab (TCZ) and to review the published evidence on the efficacy and safety of TCZ in patients with PMR. METHODS We treated 2 GC-naive patients with newly diagnosed pure PMR with monthly TCZ infusions (8mg/kg body weight) for 6 months. Disease activity and drug tolerability were assessed clinically, by laboratory tests, and bilateral shoulder ultrasonography before starting the treatment and subsequently every month during TCZ therapy. We performed a systematic literature search (PubMed until July 2012) using the terms "tocilizumab," "anti-IL-6-receptor," "polymyalgia rheumatica," "giant cell arteritis", and "large-vessel vasculitis" to identify published reports of patients with PMR treated with TCZ. RESULTS One of our patients responded well to TCZ, while the other patient required GC therapy after the 2nd TCZ infusion because of lack of appreciable clinical response. Both patients tolerated TCZ well. The review of the literature revealed 4 reports with a total of 9 patients who received TCZ for PMR. In 7 of these 9 patients, PMR was associated with giant cell arteritis. Including our patients, 5 patients received TCZ alone and 6 TCZ plus GC. A good response to TCZ treatment was observed in all patients reported in the literature without any major adverse events. CONCLUSIONS TCZ both as monotherapy and in association with GC appears to be mostly effective and safe to treat patients with PMR. However, larger controlled studies are required to confirm these favorable data.
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Affiliation(s)
- Pierluigi Macchioni
- Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
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Yoshida S, Takeuchi T, Sawaki H, Imai T, Makino S, Hanafusa T. Successful treatment with tocilizumab of pericarditis associated with rheumatoid arthritis. Mod Rheumatol 2012. [DOI: 10.1007/s10165-012-0805-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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