Etanercept: a pharmacoeconomic review of its use in rheumatoid arthritis

Research trends in contemporary health economics: a scientometric analysis on collective content of specialty journals

INTRODUCTION

Health economics is a thriving sub-discipline of economics. Applied health economics research is considered essential in the health care sector and is used extensively by public policy makers. For scholars, it is important to understand the history and status of health economics-when it emerged, the rate of research output, trending topics, and its temporal evolution-to ensure clarity and direction when formulating research questions.

METHODS

Nearly 13,000 articles were analysed, which were found in the collective publications of the ten most specialised health economic journals. We explored this literature using patterns of term co-occurrence and document co-citation.

RESULTS

The research output in this field is growing exponentially. Five main research divisions were identified: (i) macroeconomic evaluation, (ii) microeconomic evaluation, (iii) measurement and valuation of outcomes, (iv) monitoring mechanisms (evaluation), and (v) guidance and appraisal. Document co-citation analysis revealed eighteen major research streams and identified variation in the magnitude of activities in each of the streams. A recent emergence of research activities in health economics was seen in the Medicaid Expansion stream. Established research streams that continue to show high levels of activity include Child Health, Health-related Quality of Life (HRQoL) and Cost-effectiveness. Conversely, Patient Preference, Health Care Expenditure and Economic Evaluation are now past their peak of activity in specialised health economic journals. Analysis also identified several streams that emerged in the past but are no longer active.

CONCLUSIONS

Health economics is a growing field, yet there is minimal evidence of creation of new research trends. Over the past 10 years, the average rate of annual increase in internationally collaborated publications is almost double that of domestic collaborations (8.4% vs 4.9%), but most of the top scholarly collaborations remain between six countries only.

Cost-effectiveness of tumor necrosis factor-alpha inhibitors: a systematic review and meta-analysis of cost-utility studies

OBJECTIVE

To systematically review the cost-utility evidence of TNF-a-i treatment for rheumatoid arthritis (RA) and to estimate the pooled incremental net benefit (INBp).

METHODS

We selected economic evaluation studies reporting the cost-utility of TNF-a-i compared to other disease-modifying anti-rheumatic drugs (DMARDs) after a systematic search in PubMed, Embase, Scopus, and Tufts Medical Centers' cost-effective analysis registry. The results were reported as pooled INB in purchasing power parity-adjusted US dollars, along with 95% confidence intervals. We used GRADE quality assessment to present summaries of evidence and random-effects meta-analysis to synthesize cost-utility of TNF-a-i.

RESULTS

We included 86 studies for systematic review, of which 27 for meta-analysis. TNF-a-i is not cost-effective [$ -4,129(-6,789 to -1,469)] compared to other DMARDs but with high heterogeneity. There was no evidence of publication bias (p = 0.447). On separate analysis, TNF-a-i is not cost-effective [$ -4,805(-7,882 to -1,728)] compared to conventional synthetic DMARDs for RA treatment. GRADE assessment indicated very low confidence in pooled cost-utility results and likely presence of risk of bias on the overall ECOBIAS checklist in studies.

CONCLUSION

Based on the available evidence during the study period, TNF-a-i is not a cost-effective option for treating RA compared to other DMARDs. However, high heterogeneity and low confidence in GRADE quality assessment preclude the results from being generalizable.

Etanercept in Rheumatoid Arthritis: Long Term Anti-Inflammatory Efficacy in Clinical Practice

Rheumatoid Arthritis (RA) is a chronic inflammatory disease of erosive nature that tends to progress to juxta-articular destruction and ankylosis. The pathological events that lead to joint destruction are due, in part, to an enhanced expression of Tumour Necrosis Factor (TNF). It has been shown that TNF-α blocking agents significantly reduce joint inflammation and slow down the progression of radiographic joint damage. Etanercept is a biological drug obtained through recombinant DNA techniques that acts by inhibiting the cellular response mediated by TNF. The aim of this study is to evaluate the efficacy and tolerance of Etanercept in patients affected by active Rheumatoid Arthritis non- responsive to standard traditional therapies. All patients presented an improvement in the illness. Our study concords with the most recent data from literature that Etanercept acts rapidly and offers a quick and long-lasting reduction of illness activity, as well as an improvement in functional capability and quality of life in patients affected by active RA.

Health economic issues in rheumatoid arthritis

The objectives of treatment in rheumatoid arthritis (RA) are to reduce temporary symptoms due to inflammatory activity and, more importantly, to preserve function. The introduction of potent disease-modifying anti-rheumatic drugs (DMARDs) in recent years has increased the opportunities for effective treatment. However, these treatments come at a substantially higher cost than traditional DMARDs and therefore compete with other essential interventions for limited resources. They have triggered a debate on whether they represent an efficient use of resources, which patients should be treated, when, and for how long. Cost-effectiveness analysis attempts to estimate the trade-offs involved in these decisions and to provide information that can help in making them. However, in chronic progressive diseases, health gains and any potential associated economic benefits are often most evident in the long-term. As a consequence, the impact of new treatments has to be estimated using models that can project available knowledge, such as results from clinical trials or short-term follow-up studies in clinical practice, into the future. These models also allow scenarios to be explored that provide the best value for money, for example by defining subgroups for which treatment is most effective, or criteria that define when treatment should be stopped. Economic evaluation in RA has a long tradition, with the first study performed about 20 years ago. However, with the recent drug introductions, the field has witnessed an explosion of economic studies. Modelling techniques have become more sophisticated to overcome concerns about their validity. At the same time, they may appear less transparent, making it difficult for non-specialists to understand the details. This article, rather than reviewing all published models and comparing them, attempts to illustrate the inputs required for such studies, and the influence that different approaches and datasets can have on the results.

Poor reporting of search strategy and conflict of interest in over 250 narrative and systematic reviews of two biologic agents in arthritis: a systematic review

OBJECTIVE

To evaluate the quality of reviews about etanercept (ETN) and infliximab (IFX), two biologic treatments for rheumatoid arthritis (RA).

STUDY DESIGN

A comprehensive, systematic review, including searches of MEDLINE, EMBASE, and other electronic databases and hand-searches for published and unpublished literature. Two raters independently examined each article and identified systematic reviews as those including either a description of: (1) sources for identification and data retrieval; or (2) search strategy. They applied the quality of reporting of meta-analyses (QUOROM) instrument to systematic reviews.

RESULTS

Of 3,620 total citations, 281 were identified as reviews. Of these, 26 (9%) qualified as systematic rather than narrative. Overall, few reviews described selection of sources, critical appraisal, or quantitative summary or synthesis. Systematic reviews most often failed to explain validity assessment. Several articles did not disclose authors' participation in industry-funded clinical trials. Most reviews published in high impact factor and rheumatology journals did not meet many quality standards. Significant associations existed between review type (narrative vs. systematic) and reported funding (P=0.05), conflicts of interest (P=0.005), and country of publication (P<0.0001).

CONCLUSION

More than 90% of the published reviews were narrative and did not report methods and conflicts of interest in sufficient detail, raising concerns about selection and reporting bias.

N-of-1 trials of expensive biological therapies: a third way?

In developing policies for use of expensive agents, such as those used for the treatment of rheumatoid arthritis, managed care organizations have invoked "stepped care," in which physicians and patients must first try more established and less costly agents. N-of-1 clinical trials are multiple crossover trials in a single patient. In this cost-minimization analysis, we show that offering patients with rheumatoid arthritis the opportunity to participate in an n-of-1 trial comparing methotrexate with etanercept could save costs relative to open access while preserving clinical freedom relative to mandatory stepped care. In the primary model, the n-of-1 trial option was 15% more expensive than stepped care but 47% cheaper than open access to etanercept. More research is needed on the acceptability, safety, and generalizability of this promising approach.

Use of biologics in rheumatoid arthritis: Where are we going?

PURPOSE

The pharmacology, efficacy, safety, and costs of biologic agents that are approved by the Food and Drug Administration or are under review for the management of rheumatoid arthritis (RA) are discussed. Biologic therapies that are currently under investigation in early- and late-phase clinical trials are summarized at the end of this report.

SUMMARY

The use of biologic agents for the treatment of RA has significantly improved the management of this disease. Experimental and clinical studies have shown that these agents ameliorate the signs and symptoms of RA, slow radiographic progression of disease, and improve physical function and quality of life. Data also support that early initiation of therapy with these agents improves long-term outcomes. However, biologic agents are associated with adverse effects that health care providers need to recognize and manage.

CONCLUSION

Biologic agents have revolutionized the treatment of RA by reducing the signs and symptoms of RA, slowing radiographic progression of joint destruction, and improving physical function and quality of life in affected patients.

InforMatrix: treatment of rheumatoid arthritis using biologicals

This article offers an interactive decision matrix technique (InforMatrix), in which a group of experts in rheumatology determine an order of merit within the various biologicals used for rheumatoid arthritis. In this order of merit, six criteria (efficacy, safety, tolerance, ease of use, applicability and costs) are weighed against each other. Data necessary for this weighing process are derived from both literature, as well as clinical practice experience. This article provides an overview of the most relevant clinical trials on the biologicals, as well as a description of the interactive decision matrix technique. Using this interactive matrix technique makes rational consideration of the treatment options for rheumatoid arthritis possible.

[A case of recurrent breast cancer with life-threatening multiple lung metastasis markedly responding to CMF as third-line chemotherapy]

A 35-year-old woman with taxane and anthracycline-resistant recurrent breast cancer with multiple lung metastasis and carcinomatous lymphangitis was treated with CMF as third-line chemotherapy. A complete response was achieved,and the toxicities were tolerable. We thought that CMF could be a useful regimen as third-line chemotherapy for metastatic breast cancer.

The case of tumour necrosis factor-alpha inhibitors in the treatment of rheumatoid arthritis: a budget impact analysis

BACKGROUND

Treatment with tumour necrosis factor (TNF)-alpha inhibitors offers promising new opportunities to improve the health-related QOL of patients with rheumatoid arthritis (RA) in Denmark. As of September 2003, two such compounds -- infliximab and etanercept -- were registered for use by patients with RA. These drugs have shown the ability to reduce disease activity and to slow down or halt the development of new joint damage in otherwise treatment-resistant patients with RA. The acquisition cost of the drugs is high, with 1 year of treatment costing euros 9000-12,000 per patient.

OBJECTIVE

The aim of this study was to assess the potential impact on the Danish healthcare budget of prescribing infliximab or etanercept to patients with RA.

METHOD

Two treatment implementation scenarios were investigated. In the progressive scenario, all patients newly diagnosed with RA were offered TNFalpha inhibitors as the drug of first choice. In the modest scenario, only patients with insufficient disease suppression by conventional therapy with disease-modifying anti-rheumatic drugs (DMARDs) were offered TNFalpha inhibitor therapy. The budget impact analysis, which was part of a Danish health technology assessment of TNFalpha inhibitors, focused on the number of patients offered treatment during a 5-year period and resource use related to drug and staff costs. Simple sensitivity analyses assessed the consequences of changing the drug dosage, the number of patients offered treatment and the rate of treatment cessation.

RESULTS

The results suggested that both implementation strategies would impose additional costs per year on the Danish healthcare service, in the range of euros 67-188 million for the progressive scenario and euros 17-49 million for the modest scenario (price level August 2002). These costs represent between half and up to five times the amount currently used on treating patients with RA.

CONCLUSION

This analysis suggests that the introduction of TNFalpha inhibitors into the treatment regimen of patients with RA could pose a considerable financial burden on the Danish healthcare system.