Department of Rheumatology, University of Pierre and Marie Curie - Paris 6, AP-HP, Pitie Salpetrière University Hospital, 83 Boulevard de l'Hôpital, 75013 Paris, France.
Rheumatology (Oxford). 2012 Jun;51 Suppl 4:iv21-6. doi: 10.1093/rheumatology/kes088.
The total cost of RA is substantial, particularly in patients with high levels of disability. There are considerable differences in cost between countries, driven in part by differences in the use of biologic therapies. Economic evaluations are needed to assess the extra cost of using these treatments and the benefits obtained, to ensure appropriate allocation of limited health care resources. The BeSt trial, evaluating four treatment strategies, found comparable medium-term efficacy but substantially higher costs with early biologic therapy. A systematic review of such cost-effectiveness analyses concluded that biologic therapy should be used after therapy has failed with less costly alternatives such as synthetic DMARDs and glucocorticoids. Optimizing such relatively low-cost therapy to improve outcomes may delay the need for biologic therapy, thereby saving costs. A simple model has confirmed the value of this approach. The addition of modified-release prednisone 5 mg/day to existing synthetic DMARD therapy in patients with active disease resulted in improvement in DAS-28 to below the threshold level for initiation of reimbursed biologic therapy in 28-34% of patients. On a conservative estimate (i.e. assuming no further benefits beyond the 12 weeks of the study and a 12-week wait-and-see approach to starting biologic therapy), cost savings amounted to nearly € 400 per patient. While treatment decisions should never be based only on cost considerations, prolonging disease control by optimizing the use of non-biologic treatments may bring benefits to patients and also economic benefits by delaying the need for biologic treatments.
类风湿关节炎的总治疗费用相当高，尤其是在残疾程度较高的患者中。各国之间的成本存在较大差异，部分原因是生物治疗的使用存在差异。需要进行经济评估，以评估使用这些治疗方法的额外成本和获得的收益，从而确保有限的医疗保健资源得到合理分配。BeSt 试验评估了四种治疗策略，发现早期生物治疗具有可比的中期疗效，但成本要高得多。对这些成本效益分析的系统评价得出的结论是，生物治疗应在成本较低的替代疗法（如合成 DMARD 和糖皮质激素）治疗失败后使用。优化这种相对低成本的治疗方法以改善结果可能会延迟生物治疗的需求，从而节省成本。一个简单的模型证实了这种方法的价值。在有活动疾病的患者中，将 5mg/天的改良释放泼尼松加入现有的合成 DMARD 治疗中，可使 28-34%的患者的 DAS-28 改善至低于开始报销生物治疗的阈值水平。保守估计（即假设研究 12 周后没有进一步的益处，以及等待和观望 12 周开始生物治疗的方法），每个患者的成本节省近 400 欧元。虽然治疗决策绝不应仅基于成本考虑，但通过优化非生物治疗的使用来延长疾病控制可能会给患者带来益处，并通过延迟生物治疗的需求带来经济效益。
