Study Finds Tofacitinib May Result in a Lower Cost to Treat RA Than Cycling Anti-TNF Drugs

Rheumatoid arthritis (RA) has a considerable economic burden, and costly biologic drugs, including anti—tumor necrosis factor (TNF) agents, are often prescribed in cases in which patients fail to respond adequately to methotrexate.

However, a high rate of inadequate response to anti-TNFs in patients initiating biologic treatment can result in patients switching—or “cycling”—to alternative anti-TNF products. This cycling can be associated with reduced efficacy and the increased likelihood of switching to an a non—anti-TNF biologic, and may not represent a cost-effective strategy.

A recent study, funded by Pfizer, sought to assess whether tofacitinib, an oral Janus kinase inhibitor administered twice daily at a dose of 5 mg, could represent a cost-effective second-line treatment after methotrexate, third-line treatment after methotrexate and 1 anti-TNF drug, or fourth-line treatment after methotrexate and 2 anti-TNF drugs.

In total, 1321 patients were included in the analysis. The researchers used a decision-tree economic model to evaluate costs over a 2-year time horizon, with treatment response modeled on the American College of Rheumatology’s 20%, 50%, and 70% response criteria (ACR20/50/70). Response rates at 6-month intervals were derived from US prescribing information for monotherapy and combination therapy. Patients with an inadequate response to methotrexate entered the model and initiated treatment with tofacitinib, adalimumab, or etanercept. Drug costs were derived from January 2017 wholesale acquisition costs and approved dosing schedules. Other costs were derived from 2016 data.

The researchers found that:

• Based on ACR20 criteria, in patients with RA who had an inadequate response to methotrexate, the lowest total 2-year costs and per-member per-month (PMPM) costs were observed in patients receiving tofacitinib as second-line therapy.
• Based on ACR20 criteria, in patients who had an inadequate response to an anti-TNF agent after methotrexate, 2-year costs and PMPM costs were lower for patients receiving tofacitinib after 1 anti-TNF agent than those receiving tofacitinib after 2 anti-TNF agents.
• Based on ACR50 criteria, costs were also lower for those receiving tofacitinib after 1 anti-TNF agent versus 2 agents.
• Costs per ACR20 or ACR50 responder with anti-TNF exposure were lowest for those patients who received tofacitinib after etanercept, and highest for those who received tofacitinib after adalimumab followed by etanercept.

The researchers concluded that total 2-year costs and PMPM costs were lowest when tofacitinib was used as second-line treatment after methotrexate. “A treatment strategy with introduction of tofacitinib early in the sequence, as either second- or third-line therapy after [methotrexate], may be a lower-cost treatment option when compared with fourth-line introduction of tofacitinib,” write the authors.

Reference

Claxton L, Taylor M, Soonasra A, Bourret JA, Gerber RA. An economic evaluation of tofacitinib treatment in rheumatoid arthritis after methotrexate or after 1 or 2 TNF inhibitors from a US payer perspective. J Manag Care Spec Pharm. 2018;13:1-8. doi: 10.18553/jmcp.2018.17220.