Department of Management, Policy and Community Health, School of Public Health, The University of Texas Health Science Center at Houston.
Department of Biostatistics and Data Science, School of Public Health, and Center for Clinical Research and Evidence-Based Medicine, McGovern School of Medicine, The University of Texas Health Science Center at Houston.
J Manag Care Spec Pharm. 2021 Jan;27(1):73-83. doi: 10.18553/jmcp.2021.27.1.073.
For patients with rheumatoid arthritis (RA) who discontinued initial treatment with tumor necrosis factor inhibitor (TNFi), 2 approaches are commonly used: cycling to another TNFi or switching to a drug with another mechanism of action. Currently, there is no consensus on which approach to use first. A report from the IBM MarketScan Research administrative claims database showed adalimumab (cycling strategy) and abatacept (switching strategy) were more commonly prescribed after the first TNFi discontinuation. To evaluate the cost-utility of adalimumab versus abatacept in patients with RA whose initial TNFi therapy failed. A probabilistic cost-utility microsimulation state-transition model was used. Our target population was commercially insured adults with RA, the time horizon was 10 years, and we used a payer perspective. Patients not responding to adalimumab or abatacept were moved to the next drug in a sequence of 3 and, finally, to conventional synthetic therapy. Incremental cost-utility ratios (2016 USD per quality-adjusted-life-year gained [QALY)] were calculated. Utilities were derived from a formula based on the Health Assessment Questionnaire Disability Index and age-adjusted comorbidity score. Switching to abatacept after the first TNFi showed an incremental cost of just more than $11,300 over 10 years and achieved a QALY benefit of 0.16 compared with adalimumab. The incremental cost-effectiveness ratio was $68,950 per QALY. Scenario analysis produced an incremental cost-effectiveness ratio range of $44,573 per QALY to $148,558 per QALY. Probabilistic sensitivity analysis showed that switching to abatacept after TNFi therapy failure had an 80.6% likelihood of being cost-effective at a willingness-to-pay threshold of $100,000 per QALY. Switching to abatacept is a cost-effective strategy for patients with RA whose discontinue initial therapy with TNFi. Funding for this project was provided by a Rheumatology Research Foundation Investigator Award (principal investigator: Maria A. Lopez-Olivo). Karpes Matusevich's work was supported by a Doctoral Dissertation Research Award from the University of Texas, School of Public Health Office of Research. Lal reports competing interests outside of the submitted work (employed by Optum). Suarez-Almazor reports competing interests outside of the submitted work (consulting fees from Pfizer, AbbVie, Eli Lilly, Agile Therapeutics, Amag Pharmaceuticals, and Gilead). Chan, Swint, and Cantor have nothing to disclose.
对于类风湿关节炎（RA）患者，在停止初始肿瘤坏死因子抑制剂（TNFi）治疗后，通常采用两种方法：循环使用另一种 TNFi 或改用另一种作用机制的药物。目前，尚无共识确定应首先采用哪种方法。来自 IBM MarketScan 研究管理索赔数据库的报告显示，阿达木单抗（循环策略）和阿巴西普（转换策略）在首次 TNFi 停药后更常被开处方。为了评估 RA 患者初始 TNFi 治疗失败后阿达木单抗与阿巴西普的成本效用。使用概率成本效用微模拟状态转换模型。我们的目标人群是商业保险的成年 RA 患者，时间范围为 10 年，采用支付者视角。对阿达木单抗或阿巴西普无反应的患者将进入下一种药物序列，最终进入常规合成治疗。计算增量成本效用比（2016 年每增加 1 个质量调整生命年[QALY]的成本）。效用来自基于健康评估问卷残疾指数和年龄调整合并症评分的公式。与阿达木单抗相比，在首次 TNFi 后改用阿巴西普仅增加了超过 11300 美元的增量成本，实现了 0.16 的 QALY 获益。增量成本效果比为每 QALY 68950 美元。情景分析产生了每 QALY 44573 美元至 148558 美元的增量成本效果比范围。概率敏感性分析表明，在 TNFi 治疗失败后改用阿巴西普，在愿意支付每 QALY 100000 美元的阈值下，有 80.6%的可能性具有成本效益。在 TNFi 初始治疗失败后改用阿巴西普是 RA 患者的一种具有成本效益的策略。本项目的资金由风湿病研究基金会研究员奖（主要研究员：Maria A. Lopez-Olivo）提供。Karpes Matusevich 的工作得到了德克萨斯大学公共卫生办公室博士论文研究奖的支持。Lal 报告了与提交工作无关的竞争利益（受雇于 Optum）。Suarez-Almazor 报告了与提交工作无关的竞争利益（辉瑞、艾伯维、礼来、敏捷治疗、Amag 制药和吉利德的咨询费）。Chan、Swint 和 Cantor 没有要披露的内容。
