A systematic review of the effectiveness of adalimumab

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Health economics
Strategies including two TNF inhibitors
consecutively
Here the relevant decision is, having used one
TNF inhibitor, whether to use a second TNF
inhibitor or to revert to conventional DMARDs.
Only the case where the first TNF inhibitor is used
as third line therapy is considered, and
adalimumab and etanercept are considered only as
single therapy. Any one of the three TNF inhibitors
could be the first choice. Thus, there are three
strategy sets to consider, each with three options.
The first of these strategy sets (Table 38) starts with
methotrexate, followed by sulfasalazine (with or
without methotrexate) and then adalimumab. The
divergence point comes immediately after
adalimumab. Options 1 and 2 are to treat with
etanercept and infliximab, respectively, if
adalimumab fails and then continue the baseline
strategy from leflunomide onwards. In the
comparator, option 3, adalimumab is followed by
leflunomide and the baseline strategy. The
equivalent strategy sets for other choices of first
TNF inhibitor are shown in Tables 87 and 88
(Appendix 9).
Strategies including all three TNF inhibitors
consecutively
Here the relevant decision is, having used two
TNF inhibitors, whether to use a third TNF
inhibitor or to revert to conventional DMARDs.
Again only the case where the first TNF inhibitor
is used as third-line therapy is considered; that is,
after sulfasalazine and methotrexate have been
TABLE 38 Strategy set with adalimumab followed by another TNF inhibitor
tried (according to current NICE guidance), and
adalimumab and etanercept are considered only as
single therapy. Any one of the three TNF
inhibitors could be the first fixed choice, with
either of the other two as the second fixed choice.
Thus, there are six strategy sets to consider, each
with two options.
The strategy set shown in Table 39 starts with
methotrexate, followed by sulfasalazine (with or
without methotrexate) and then adalimumab
followed by etanercept. The divergence point
comes immediately after etanercept. Option 1 is to
use infliximab after this and then continue the
baseline strategy from leflunomide onwards;
option 2 is to forgo infliximab and continue
directly with leflunomide. The other five strategy
sets, which are similar, are given in Tables 89–93,
(Appendix 9).
Data used in the BRAM
The main source of data is the current review for
TNF inhibitors and published literature for other
data.
Initial patient data
Table 40 shows the initial age and sex distribution,
based on UK data from Wiles et al. 172 The starting
distribution of HAQ scores, shown in Table 41, is
also based on Wiles. 172
Starting treatments
In previous versions of the BRAM, the HAQ
improvement (decrease) on starting any treatment
Moves dependent on toxicity
Treatment Always move to Relevant toxicity If toxic, move to Otherwise, move to
MTX MTX SSZ MTX+SSZ
SSZ Adal
MTX+SSZ Adal
Adal Divergence point
Option 1 Etan
Etan LEF
Option 2 Infl+MTX
Infl+MTX LEF
Option 3 LEF
LEF GST
GST AZA
AZA CyA
CyA CyA or MTX DPen CyA+MTX
CyA+MTX DPen
DPen Pall