The standard beginning therapy for rheumatoid arthritis (RA) consists of methotrexate as a disease modifying anti-rheumatic drug (DMARD) and either a non-steroidal anti-inflammatory drug (NSAID) or low dose prednisone. While these drugs do work to a certain extent, they rarely induce remission.
TNF- inhibitors such as Enbrel, Humira, and Remicade have revolutionized our approach to RA and have enabled rheumatologists to get patients into remission.
The high cost of biologic agents has brought "pharmacoeconomic" considerations as a factor to deal with in the care of patients with rheumatoid arthritis. There is an increasing amount of data confirming the substantial cost implications of various arthritic conditions. For the TNF inhibitors, the clinical effectiveness needs to be factored into an assessment of their value.
In RA, there is a growing body of data addressing the potential cost-effectiveness of TNF inhibitors. As a result of their remarkable clinical efficacy, it appears that TNF inhibitors may have an incremental cost efficacy in RA.
Much of the data upon which this is based come from follow up of patients participating in clinical trials of these agents over the past decade. In general, changes in health states, using specific quantifiable measures of performance of activities of daily living have provided proof of cost effectiveness.
Using anti-TNF drugs and then measuring their effect on ability to function has provided the ability to define the level of response to treatment in terms of quality-adjusted life years (QALYs) gained.
A number of studies have shown improvements in work status with treatment.
Other studies have begun to explore the effect of TNF inhibitor treatment on employability; in one study, such treatment significantly improved employability and reduced days missed from work.
In addition, ongoing studies are developing models comparing the outcomes of patients who are capable of productive work versus what would happen in the event of progressive disease and crippling. A patient who doesn't have access to an anti-TNF drug and becomes crippled can't be a positive producer to the economy. On top of that, there would be a negative impact on the economy in terms of dollars needed for health care support of that patient.
Unfortunately, insurance companies who set up barriers to the access of these medicines have a very shortsighted view of the picture. Hopefully, further studies that document the value to society and to the individual of remaining productive and having a better quality of life will change this situation for the better.
Nathan Wei, MD, FACP, FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland (http://www.aocm.org). He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine and consultant to the National Institutes of Health. For more info: Arthritis Treatment
