From University of British Columbia and St Paul's Hospital, Vancouver, British Columbia, Canada; Palo Alto Veterans Affairs (VA) Health Care System, Palo Alto, and Stanford University School of Medicine, Stanford, California; VA Nebraska-Western Iowa Health Care Center and University of Nebraska Medical Center, Omaha, Nebraska; Boston University School of Medicine, Boston, Massachusetts; and University of Toronto and Mount Sinai Hospital, Toronto, Ontario, Canada.
Ann Intern Med. 2017 Jul 4;167(1):8-16. doi: 10.7326/M16-0713. Epub 2017 May 30.
The RACAT (Rheumatoid Arthritis Comparison of Active Therapies) trial found triple therapy to be noninferior to etanercept-methotrexate in patients with active rheumatoid arthritis (RA).
To determine the cost-effectiveness of etanercept-methotrexate versus triple therapy as a first-line strategy.
A within-trial analysis based on the 353 participants in the RACAT trial and a lifetime analysis that extrapolated costs and outcomes by using a decision analytic cohort model.
The RACAT trial and sources from the literature.
Patients with active RA despite at least 12 weeks of methotrexate therapy.
24 weeks and lifetime.
Societal and Medicare.
Etanercept-methotrexate first versus triple therapy first.
Incremental costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).
RESULTS OF BASE-CASE ANALYSIS: The within-trial analysis found that etanercept-methotrexate as first-line therapy provided marginally more QALYs but accumulated substantially higher drug costs. Differences in other costs between strategies were negligible. The ICERs for first-line etanercept-methotrexate and triple therapy were $2.7 million per QALY and $0.98 million per QALY over 24 and 48 weeks, respectively. The lifetime analysis suggested that first-line etanercept-methotrexate would result in 0.15 additional lifetime QALY, but this gain would cost an incremental $77 290, leading to an ICER of $521 520 per QALY per patient.
Considering a long-term perspective, an initial strategy of etanercept-methotrexate and biologics with similar cost and efficacy is unlikely to be cost-effective compared with using triple therapy first, even under optimistic assumptions.
Data on the long-term benefit of triple therapy are uncertain.
Initiating biologic therapy without trying triple therapy first increases costs while providing minimal incremental benefit.
The Cooperative Studies Program, Department of Veterans Affairs Office of Research and Development, Canadian Institutes for Health Research, and an interagency agreement with the National Institutes of Health-American Recovery and Reinvestment Act.
RACAT（类风湿关节炎的活性治疗比较）试验发现，三联疗法在活动性类风湿关节炎（RA）患者中不劣于依那西普-甲氨蝶呤。
确定依那西普-甲氨蝶呤与三联疗法作为一线策略的成本效益。
基于 RACAT 试验的 353 名参与者进行的试验内分析和通过使用决策分析队列模型推断成本和结果的终身分析。
RACAT 试验和文献来源。
在至少 12 周的甲氨蝶呤治疗后仍有活动性 RA 的患者。
24 周和终身。
社会和医疗保险。
依那西普-甲氨蝶呤首先与三联疗法首先。
增量成本、质量调整生命年（QALY）和增量成本效益比（ICER）。
试验内分析发现，依那西普-甲氨蝶呤作为一线治疗方法提供了略微更多的 QALY，但累积了更高的药物成本。策略之间其他成本的差异可以忽略不计。依那西普-甲氨蝶呤和三联疗法的一线治疗的 ICER 分别为每 QALY270 万美元和每 QALY0.98 万美元，分别为 24 周和 48 周。终身分析表明，一线依那西普-甲氨蝶呤将导致 0.15 个额外的终身 QALY，但这一增益将额外花费 77290 美元，导致每位患者每 QALY 521520 美元的 ICER。
从长期角度考虑，与首先使用三联疗法相比，初始策略使用依那西普-甲氨蝶呤和具有类似成本和疗效的生物制剂不太可能具有成本效益，即使在乐观的假设下也是如此。
三联疗法长期获益的数据不确定。
不首先尝试三联疗法而直接开始生物治疗会增加成本，同时只提供最小的增量收益。
合作研究计划、退伍军人事务部研究与发展办公室、加拿大卫生研究院和与美国国立卫生研究院-复苏与再投资法案的机构间协议。
