Department of Rheumatology, Brest University, CHU Brest, Brest, France.
Rheumatology (Oxford). 2010 Apr;49(4):733-40. doi: 10.1093/rheumatology/kep434. Epub 2010 Jan 16.
Modern treatment of RA includes the use of biologics. Their cost is high and comparison between different treatment strategies is needed.
Direct medical costs of RA in France were evaluated based on expert opinion. Then, simulation-decision analytical models were developed to assess four biologic treatment sequences over 2 years in patients failing to respond to at least one anti-TNF agent. Effectiveness was expressed in theoretical expected number of days (TEND) in remission or low disease activity [low disease activity score (LDAS)] based on DAS-28 scores.
Direct medical costs of RA in France (excluding the cost of biologics) were estimated at euro 905 (s.d. 263) for 6 months and euro 696 (s.d. 240) for each subsequent 6 months (P < 0.001) for patients achieving LDAS and euro 1215 for 6 months (s.d. 405) for patients not achieving LDAS. Based on LDAS criteria, using abatacept after an inadequate response to the first anti-TNF agent (etanercept) appeared significantly (P < 0.01) more efficacious over a 2-year period (102 TEND) compared with using rituximab at a 6-month re-treatment interval (82 TEND). Mean cost-effectiveness ratios showed significantly lower costs (P < 0.01) per TEND with abatacept as second biologic agent (euro 278) compared with rituximab (euro 303). After an inadequate response to two anti-TNF agents, using abatacept also appeared significantly more efficacious than an anti-TNF agent (P < 0.01). All comparisons were confirmed when using remission criteria instead of LDAS.
Advanced simulation models based on clinical evidence and medical practice appear to be a promising approach for comparing cost-effectiveness of biologic strategies in RA.
类风湿关节炎（RA）的现代治疗包括生物制剂的应用。这些药物的成本很高，因此需要比较不同的治疗策略。
根据专家意见评估法国 RA 的直接医疗成本。然后，开发了模拟决策分析模型，以评估在至少一种抗 TNF 药物治疗失败的患者中，两种生物制剂治疗方案在 2 年内的 4 种治疗顺序。基于 DAS28 评分，采用缓解或低疾病活动度（低疾病活动评分[LDAS]）的理论预期天数（TEND）来表示疗效。
在实现 LDAS 的患者中，法国 RA 的直接医疗成本（不包括生物制剂的成本）估计为 6 个月时为 905 欧元（标准差 263），随后每 6 个月为 696 欧元（标准差 240）（P<0.001），而未达到 LDAS 的患者则为 6 个月时 1215 欧元（标准差 405）。根据 LDAS 标准，在首次抗 TNF 药物（依那西普）治疗效果不佳后使用阿巴西普（abatacept）在 2 年内（102 TEND）明显更有效（P<0.01），而在 6 个月的再治疗间隔使用利妥昔单抗（rituximab）（82 TEND）。在使用 LDAS 标准时，使用阿巴西普作为二线生物制剂的成本效益比显示出明显更低的成本（P<0.01），每 TEND 为 278 欧元，而使用利妥昔单抗为 303 欧元。在对两种抗 TNF 药物治疗效果不佳后，使用阿巴西普也明显比使用抗 TNF 药物更有效（P<0.01）。当使用缓解标准而不是 LDAS 时，所有比较均得到确认。
基于临床证据和医疗实践的高级模拟模型似乎是比较 RA 中生物制剂策略成本效益的有前途的方法。
