Choosing the Best Rheumatoid Arthritis Treatment

Rheumatoid arthritis triple therapy less costly and still effective compared to other option

/ Author:  / Reviewed by: Robert Carlson, M.D Beth Bolt, RPh

(RxWiki News) It's often thought that the most effective medication for a condition is always the best to use. But if the effectiveness of the medication is only a little higher, and the costs are a lot higher, that may not be the case.

A recent study found that two different treatments for rheumatoid arthritis offer similar benefits but have very different price tags.

Many individuals with rheumatoid arthritis are prescribed a medication called methotrexate. The brand name is Rheumatrex or Trexall.

Then, if their disease does not improve, they may be prescribed three medications together or a different medication that tries to reduce the body's cause of inflammation.

Both of these options offer benefits to patients over the long-term, but the second option is much more costly.

"Ask your doctor about rheumatoid arthritis treatments."

The study, led by Hawre Jalal, a PhD student in the School of Public Health at the University of Minnesota, compared the cost effectiveness of different therapies for treating rheumatoid arthritis.

The researchers compared a two-medication combination to a three-medication combination to see whether one option was more or less effective and cost more or less.

One combination was called triple therapy and included the medications methotrexate, sulfasalazine (brand name Azulfidine) and hydroxychloroquine (brand name Plaquenil).

All three of these medications are in a group called disease modifying antirheumatic drugs, or DMARDs.

The other combination included methotrexate and a medication called anti-TNF therapy. TNF stands for "tumor necrosis factor," which refers to the inflammatory response in a body that leads the immune system to attack itself in autoimmune diseases like rheumatoid arthritis.

To compare these therapy regimes, the researchers looked at both the quality of life of participants and at the costs involved in the different options.

First, all of the patients with early rheumatoid arthritis were started on methotrexate. If their disease continued to worsen, they were "stepped up" to either receiving the triple therapy or to taking etanercept (brand name Enbrel), an anti-TNF medication.

The researchers used a computer program to mathematically estimate their results based on their initial data, pulled from an already ongoing rheumatoid arthritis trial and a databank of information on patients with rheumatic diseases.

To compare cost differences, the researchers estimated that 22 percent of patients taking the triple therapy would stop taking it each year, and 10 percent of those taking etanercept would stop taking it each year.

The researchers found that the lifetime benefits of the different therapy options were similar in terms of patients' quality of life.

They found the use of etanercept to be slightly more effective than the use of triple therapy, but was considerably more expensive.

In fact, using etancercept cost an additional $837,100 for each additional "quality of life year" for patients.

"The benefits from all strategies were comparable, but biologics strategies [etanercept] were almost twice more expensive than triple strategies, producing a cost-effectiveness ratio greater than what most healthcare settings find acceptable," the researchers concluded.

“The current American College of Rheumatology treatment guidelines for early rheumatoid arthritis indicate initiating after methotrexate either a concomitant anti-TNF biologic [like etanercept] or another non-biologic DMARD depending on the severity of the prognosis,” said co-author Kaleb Michaud, PhD, assistant professor at the University of Nebraska Medical Center, in a prepared statement.

"While this study should not change those guidelines, our results suggest that physicians should consider use of triple therapy as a viable alternative to a biologic for patients where costs may be an impediment to care," Dr. Michaud said.

Adam Powell, PhD, a health economist and President of Payer+Provider Syndicate, evaluated what the study found.

"This study suggests that immediate triple therapy provides better outcomes at a lower cost than step-up triple therapy and step-up etanercept therapy," he said. "Immediate etanercept therapy provided patients with an additional 0.222 Quality-Adjusted Life Years, relative to immediate triple therapy."

He explained that Quality-Adjusted Life Years (QALYs) are used to measure the impact of a treatment on both the longevity and quality of life of a person receiving the treatment.

"While small, a 0.222 QALY gap mathematically represents roughly three months of life in perfect health, or a greater number of months of life in diminished health," Dr. Powell explained.

"The additional cost of immediate etanercept, relative to immediate triple therapy, is $185,700," he said. "While perhaps not cost-effective by most standards, immediate etanercept therapy may appeal to some patients."

The study was presented October 29 at the American College of Rheumatology Annual Meeting in San Diego.

This study has not yet been published in a peer-reviewed journal, and its findings should be interpreted with caution.

Information on funding was unavailable. One author has links to the National Data Bank for Rheumatic Diseases. Another has links to Roche/Genentech, UCB, Janssen, CORRONA, Amgen, Pfizer, BMS, Crescendo and Abb Vie.

Review Date: 
October 25, 2013
Last Updated:
October 31, 2013