Assessing Economic Effects of Cycling vs Swapping After Initial TNFi Failure in RA

Investigators reviewed economic analyses comparing cycling TNFi with swapping with another therapy in patients with rheumatoid arthritis who did not respond to initial TNFi therapy.

Several economic modeling and analysis techniques exist comparing different therapeutic strategies following lack of response with tumor necrosis factor inhibitor (TNFi) in patients with rheumatoid arthritis (RA), but a uniformed methodology is needed to report economic evaluations of cycling vs swapping after TNFi, according to study results published in Arthritis Care & Research.

In this systematic review, researchers searched major databases for studies comparing the cost-effectiveness of 2 different therapeutic approaches commonly used after TNFi failure in patients with RA: switching to a therapy with a different mechanism of action or using an alternative TNFi. After applying the search criteria, the investigators found 7 studies, which consisted of 19 comparisons. The majority of economic models included a lifetime horizon, came from a payer perspective, used a 6-month cycle duration, and measured treatment efficacy with American College of Rheumatology improvement criteria.

Related Articles

After analysis, the researchers found a broad range of study designs, major assumptions, and model structures, which greatly affected individual study results. In addition, the team reported that the median incremental cost-effectiveness ratio was $70,332 per quality-adjusted life year for the 2 treatment approaches. In addition, data show that rituximab was more effective and less expensive than TNFi in most comparisons and intravenous abatacept vs TNFi was less cost-effective than rituximab.

“Common influential parameters in sensitivity analyses were the rituximab dosing schedule, assumptions regarding disease progression, and estimation of utilities,” the researchers wrote.

The primary study limitation was the intrinsic heterogeneity in the economic evaluations.

“Future research should determine the treatment sequences used in real-world clinical practice and the length of time patients continue taking each agent,” they concluded.


Karpes AR, Suarez-Almazor ME, Cantor SB, et al. Systematic review of economic evaluations of cycling versus swapping in patients with rheumatoid arthritis after failure to tumor necrosis factor inhibitors [published online February 23, 2019]. Arthritis Care Res. doi:10.1002/acr.23859