De-escalation of biologic disease-modifying antirheumatic drug (bDMARD) therapies in patients with rheumatoid arthritis (RA) is associated with significant cost savings, but results in decreases in quality of life compared with standard care, according to research published in PLoS One.
Researchers conducted a cost-utility analysis of patients with RA undergoing bDMARD therapy in order to compare continuing treatment (standard) with 3 treatment modalities: tapering (immediate 50% dose reduction), withdrawal (immediate 100% dose reduction), and tapering followed by withdrawal. Patients in this study had achieved either remission or low disease activity.
After 120 cycles over 30 years, the base model developed by investigators yielded negative incremental costs, in addition to negative incremental costs and negative incremental quality-adjusted life years (QALYs) for all 3 de-escalation approaches vs standard care. The incremental costs per patient were -€78,845 for tapering, -€121,691 for withdrawal, and -€107,696 for tapering followed by withdrawal. Incremental reductions in QALYs were -0.1498, -0.5611, and -0.4354, respectively, while incremental cost-effectiveness ratios were €526,254, €216,879, and €247,987, respectively.
Investigators conducted sensitivity analyses, adjusting for changes in parameters related to costs and quality of life and found that incremental QALYs were sensitive to changes only in transition probabilities in remission. Across all 3 models, pharmaceutical costs for bDMARDs were the most influential cost parameters; application of the upper and lower bound resulted in negative incremental costs of up to €179,002 and €64,371 when bDMARDs are withdrawn.
Finally, when researchers applied a utility decrement to assess for the side effects of bDMARDs, tapering became the dominant strategy. Savings generated per QALY lost were substantially increased for both withdrawal and dose reduction strategies. Investigators found that self-withdrawal after 2, 3, or 5 years of stable remission resulted in reductions in savings and loss of QALYs across all interventions compared with standard care.
The study had several important study limitations. Researchers noted that clinical accuracy might be different across disease activity parameters. Patients with medium and high disease activity were combined into one cohort owing to study data limitations, and models may have underestimated direct costs because the researchers used cost registry data. Additionally, they assumed that patients were compliant over all 30 years, and finally, dose reduction to withdrawal models was modeled using results from tapering studies.
“Our findings suggest that de-escalating bDMARDs through tapering … withdrawal, or tapering followed by withdrawal in patients with RA may lead to high cost savings compared with standard care. However, these savings are accompanied by a decrease in quality of life,” the researchers concluded, adding that “more research using data from clinical practice is necessary to validate our findings.”
Birkner B, Rech J, Stargardt T. Cost-utility analysis of de-escalating biological disease-modifying anti-rheumatic drugs in patients with rheumatoid arthritis. PLoS One. 2020;15(1):e0226754.