Cost-Effectiveness of Biologics as First-Line Treatment of Rheumatoid Arthritis: Case Closed?

Rheumatoid arthritis (RA) is an autoimmune, multisystem disease characterized by chronic inflammation and, ultimately, destruction of joints. Left unchecked, it leads to a high burden of disease, early loss of work capacity, major morbidity, and increased mortality. The concept of a window of opportunity—that early and aggressive treatment could prevent many of the long-term consequences of the disease—was introduced in the early 1990s (1). The drugs available at that time, including disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids, were tested in different combination strategies and proven through tight-control strategies to be effective in both the short and the long term. Treatment of RA received a subsequent boost from the introduction of new biologic therapies, beginning with tumor necrosis factor (TNF)-α inhibitors and recently followed by agents that modulate other targets. With 1 exception, all have shown great efficacy that matches that of optimum conventional combination therapies, as well as a good safety profile and ease of use.

The main problem with biologics is that they are priced at the maximum level the market will bear. Since their introduction, the number of diseases that can be treated with biologics (and thus the number of potential patients that can be treated) has increased substantially, and competition is intense. Prices have defied these economic pressures and remained constant. Physicians and reimbursement agencies are under extreme marketing pressure to allow patients earlier access to biologic therapy, and several trials in early RA suggest that including a biologic in initial combination therapy is a good idea, although 1 trial (2) showed that such therapy was no more than equivalent to a combination regimen of conventional DMARDs and glucocorticoids. Unfortunately, trials that compare a biologic head-to-head with optimum conventional treatments are rare, because the industry has no impetus to …