Rheumatoid Arthritis

Comparing 2-Year Cost-Effectiveness of 2 Tapering Strategies in Patients With RA

Avatar photoSheila Jacobs
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Joint or cervical spine ankylosis may occur in RA.1 Joint ankylosis usually affects small joints of the hand, wrists, ankle, or forefoot. Although joint ankylosis was once common, widespread DMARD use has nearly eliminated this complication. Studies suggest that bone ankylosis is infrequent (0.8%) and usually occurs in patients with long-standing RA.1 Patients with joint ankylosis of the wrist appear more likely to develop cervical ankylosis.1 The reported prevalence of cervical spine ankylosis ranges from 9% to 80%, depending on the imaging modality used.1 Patients develop bony erosions, ligamentous laxity, and complete fusion.8 Ankylosis of the cervical facet joints typically occurs at the atlanto-occipital and atlanto-axial joints.9 Patients are often asymptomatic, but may have pain, neuropathy, or severe myelopathy and require surgical intervention. Use of DMARDs appears to prevent cervical ankylosis, but does not prevent its progression.8

Joint or cervical spine ankylosis may occur in RA.1 Joint ankylosis usually affects small joints of the hand, wrists, ankle, or forefoot. Although joint ankylosis was once common, widespread DMARD use has nearly eliminated this complication. Studies suggest that bone ankylosis is infrequent (0.8%) and usually occurs in patients with long-standing RA.1

Patients with joint ankylosis of the wrist appear more likely to develop cervical ankylosis.1 The reported prevalence of cervical spine ankylosis ranges from 9% to 80%, depending on the imaging modality used.1 Patients develop bony erosions, ligamentous laxity, and complete fusion.8 Ankylosis of the cervical facet joints typically occurs at the atlanto-occipital and atlanto-axial joints.9 Patients are often asymptomatic, but may have pain, neuropathy, or severe myelopathy and require surgical intervention. Use of DMARDs appears to prevent cervical ankylosis, but does not prevent its progression.8

In patients with rheumatoid arthritis, the use of 2 different tapering strategies—tapering csDMARDs first, followed by the TNF inhibitor, or vice versa—has been shown to be equally cost-effective.

In patients with rheumatoid arthritis (RA), the use of 2 different tapering strategies—that is, tapering conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) first, followed by the tumor necrosis factor (TNF) inhibitor, or vice versa—has been shown to be equally cost-effective. Results of the analysis were published in Annals of the Rheumatic Diseases.

The current study evaluated 2-year data from the multicenter, single-blinded Tapering strategies in Rheumatoid Arthritis (TARA) trial, which was conducted in The Netherlands. Recognizing that current European League Against Rheumatism guidelines recommend tapering medication in patients with RA who are in remission, the investigators sought to compare the 2-year cost-utility ratio of tapering TNF inhibitors first or csDMARDs first, followed by tapering the other regimen, or the reverse order.

The primary study outcome of the TARA study was the number of disease flares. With respect to evaluating the cost-effectiveness of each tapering strategy, the main outcome was the incremental cost-effectiveness ratio (ICER)—that is, the ratio of the difference in costs compared with the difference in quality-adjusted life years (QALYs) between both tapering strategies.

The study enrolled patients with RA who were being treated with both a csDMARD and a TNF inhibitor. All participants had well-controlled disease (ie, disease activity score of ≤2.4 and swollen joint counts of ≤1) for ≥3 months. A total of 189 participants were enrolled in the trial. Of these patients, 95 started tapering their csDMARD first and 94 tapered their TNF inhibitor first. The QALYs of the participants were 1.65 ± 0.22 and 1.64 ± 0.22, respectively.

The costs of medications were significantly lower in the participants who tapered the TNF inhibitor first, whereas the indirect costs were higher because of a greater loss of productivity (P =.10). Thus, total costs were €38 833 ± €39 616 for tapering csDMARDs first vs €39 442 ± €47 271 for tapering the TNF inhibitor first—a difference that was not statistically significant (P =.88).

Regarding willingness-to-pay (WTP) levels of <€83 800 tapering, the strategy of tapering the csDMARD first has the highest probability of being cost-effective, whereas for WTP levels of

>€83 800 tapering, the strategy of tapering the TNF inhibitor first has the highest probability.

Limitations of the study include that the targeted sample size was not reached, and generalizability of the study may be difficult since every country has its own social security and healthcare system.

The investigators concluded that the current economic assessment demonstrates that the costs are similar for both of the tapering strategies. Based on the viewpoint being considered—that is, payer’s or societal perspective—and the WTP threshold, the csDMARD or the TNF inhibitor can be tapered first in patients with RA.

Reference

van Mulligen E, Weel AE, Kuijper TM, et al. Two-year cost effectiveness between two gradual tapering strategies in rheumatoid arthritis: cost-utility analysis of the TARA trial. Ann Rheum Dis. 2020;79(12):1550-1556. doi: 10.1136/annrheumdis-2020-217528

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