Study Challenges Economic Viability of Rheumatoid Arthritis Treatments

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The investigation of 11 alternative DMARD therapies in combination with methotrexate shows a lack of economic attractiveness compared with the standard of care.

New data found despite the effective reduction in disease activity and an improvement in quality of life, combinations of MTX with biologic disease-modifying antirheumatic drugs (bDMARDs), targeted synthetic DMARDs (tsDMARDs), and biosimilar DMARDs (bsDMARDs) did not demonstrate a favorable economic attractiveness when compared with the standard treatment approach for patients with rheumatoid arthritis (RA).1

The introduction of bDMARDs, tsDMARDs, or bsDMARDs has significantly improved clinical outcomes among those with high disease activity in this patient population

These treatments are generally associated with higher costs than standard treatment. The investigation aimed to evaluate the cost-effectiveness of various treatment strategies for patients with RA who have high disease activity and have not responded to conventional synthetic DMARDs (csDMARDs).

Evaluating the Cost-Effectiveness of DMARDs

The investigators led by Juthamas Prawjaeng, Pharm D, Siriraj Health Policy Unit, Faculty of Medicine Siriraj Hospital, Mahidol University, employed a Markov model constructed from a societal perspective to assess costs and health outcomes in terms of quality-adjusted life years over a lifetime of 100 years, accounting for a 3% annual discount rate.

The evaluated interventions were 11 alternative treatment strategies, including 5 bDMARDs, 2 tsDMARDs, and 4 bsDMARDs, all in combination with methotrexate (MTX). Analyses were conducted to compare with the standard of care: cyclosporine and azathioprine.

Direct and nonmedical care costs were estimated based on resource utilization and the standard 2022 cost. Investigators gathered utility and transitional probabilities from 3 advanced tertiary hospitals. The efficacy of each treatment was estimated according to a network meta-analysis.

Lifetime costs, quality-adjusted life years, and incremental cost-effectiveness ratios were calculated and compared with a cost-effectiveness threshold of 160,000 THB per quality-adjusted life years gained, equivalent to US $4634. Probabilistic and one-way sensitivity analyses were performed to assess parameter uncertainties.

Rheumatoid Arthritis Therapies are not Economically Viable

In relation to standard treatment, combinations of bDMARDs, tsDMARDs, or bsDMARDs with MTX resulted in quality-adjusted life year gains ranging from 0.09 to 0.33, with additional costs ranging from 550,986 to 2,096,744 THB, equating to $15,957 to $60,722.

The ICERs for these combinations ranged from 2.3 to 8.1 million THB per quality-adjusted life years, or $65,935 to $234,996, compared with the standard of care. None of the alternative treatment strategies were found to be cost-effective within the Thai context.

The results were sensitive to the mortality hazard ratio of patients with high disease activity, the study reported. While the combinations of MTX with bDMARDs, tsDMARDs, or bsDMARDs resulted in reduced disease activity and improved patient quality of life, they were not economically attractive compared to the standard practice.

"However, they reduced disease activity and improved patient quality of life," the investigators wrote. "The price negotiation process for these treatments must be conducted to ensure their financial value and affordability before they are included in the pharmaceutical reimbursement list."


  1. Prawjaeng J, Leelahavarong P, Budtarad N, Pilasant S, Chanjam C, Katchamart W, Narongroeknawin P, Kitumnuaypong T. Cost-utility analysis of biologic disease-modifying antirheumatic drugs (bDMARDs), targeted synthetic DMARDs (tsDMARDs) and biosimilar DMARDs (bsDMARDs) combined with methotrexate for Thai rheumatoid arthritis patients with high disease activity. BMC Health Serv Res. 2023 May 31;23(1):561. doi: 10.1186/s12913-023-09595-1. PMID: 37259090; PMCID: PMC10230705.