OBJECTIVES: Rheumatoid arthritis (RA) has a considerable disease burden with life-long physical limitations, reduced work productivity and high societal costs. Trials on arthralgia at-risk for RA are therefore conducted, aiming to intercept evolving RA and reduce the disease burden. A 1-year course of methotrexate in patients with clinically suspect arthralgia (CSA) caused sustained improvements in subclinical joint inflammation and physical impairments. Since the cost-effectiveness of treatment in CSA has never been investigated, we investigated whether methotrexate is cost-effective.
METHODS: Cost-effectiveness was assessed using the TREAT EARLIER trial. 236 patients with CSA with subclinical joint inflammation were randomised to 1-year treatment with methotrexate, or placebo, and followed for 2 years. Cost-effectiveness was analysed by computing costs and effects. For costs, both a societal perspective (healthcare-productivity and work-productivity costs) and a healthcare perspective (healthcare costs only) were used. For effects, quality adjusted life years (QALYs) were used.
RESULTS: Treatment increased QALYs by 0.041 (95% CI -0.050 to 0.091), and reduced costs with €-4809 (95% CI -12 382 to 2726) over the course of 2 years using a societal perspective, with a probability of 88.1% that treatment was cost-effective. From a healthcare perspective, the cost-difference between treatment and placebo was estimated at €-418 (95% CI -1198 to 225).
CONCLUSION: A fixed treatment course in individuals with arthralgia at-risk for RA and MRI-detected subclinical joint inflammation resulted in better work productivity, lower healthcare costs and improved quality of life over the course of 2 years; with the largest gain in productivity costs. This is the first evidence that methotrexate treatment aiming at secondary prevention in arthralgia at-risk for RA is cost-effective.
| Discipline Area | Score |
|---|---|
| Physician |  |
| Nurse | |
Nurse rater
This article bears on the question of whether there is cost-utility in initiating methotrexate in patients with clinically suspect arthralgia or subclinical inflammation detected with MRI, even if auto-antibody negative, represent a patient population in whom probability of progression to RA is reduced, or if initiating methotrexate otherwise favorably impacts overall outcome over 12 month and 24-month horizon. Robust sensitivity analyses in this study support a conclusion that compared to placebo, methotrexate dominates. Criteria for "at risk for RA" defines a preemptive (or secondary prevention strategy) window of opportunity for disease-modifying drugs, and methotrexate as first-line relatively inexpensive DMARD would be attractive on basis of cost-utility. A similar study might extend the horizon and include biologic DMARDs.
Physician rater
This is a good step forward to analyze the cost-effectiveness of methotrexate in early subclinical RA/CSA. However, the implications of using methotrexate in clinical practice would require further studies to delve into the heterogeneity of the condition and to ensure that the benefits clearly outweigh the risks from treatment.
Physician rater
In early RA, many patients present a symptomatic phase without clearly defined synovitis. This showed that 1-year course of MTX (mean dose of 19.1 mg) in patients with clinically suspect arthralgia and MRI criteria improved subclinical joint inflammation and physical function, and the cost-effectiveness of the therapy was observed. The study was, however, time-limited (2 years) and the number of patients was small. A longer study to observe whether "preventive" therapy with MTX would influence developing future RA would be interesting to do.
, McMaster University