A systematic review of the effectiveness of adalimumab

following properties, according to the values of L
and U:
● U < 5000 or L > 200,000: U/L < 2.5
● U < 10,000 or L > 100,000: U/L < 2.0
● U < 20,000 or L > 50,000: U/L < 1.5
● U < 30,000 or L > 30,000: U/L < 1.2
● L < 30,000 and U > 30,000: U/L < 1.1.
In cases where there were more than two options
to compare, the more important comparisons are
those between an option including a TNF
inhibitor and the baseline without that TNF
inhibitor. These are referred to as ‘major
comparisons’. Comparisons between different
strategies including TNF inhibitors are referred to
as ‘minor comparisons’. Results are given for the
following minor comparisons:
● effect of adding methotrexate (adalimumab plus
methotrexate versus adalimumab alone,
etanercept plus methotrexate versus etanercept
alone)
● comparison between monotherapies
(adalimumab versus etanercept alone)
● comparison between combinations with
methotrexate (adalimumab plus methotrexate
versus etanercept plus methotrexate versus
infliximab plus methotrexate).
The model was first run with 10,000 patients. If
any major comparison gave insufficiently precise
results, then the number of patients was increased
to 20,000, then to 40,000, then to 100,000, then
to 200,000, and so on as necessary until all major
comparisons gave sufficiently precise results. If any
quoted minor comparison was insufficiently
precise at this stage, the number of patients was
increased once more. The actual number of
patients modelled in each case is stated.
TABLE 50 Summary of base-case ICERs for each TNF inhibitor (alone and with MTX)
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Health Technology Assessment 2006; Vol. 10: No. 42
TNF inhibitor Comparator Cost per QALY (£) First-line use (early RA)
Usage consistent with 2002 NICE guidance
Third line Last in Third line
(late RA data) strategy (using early
RA data)
Adalimumab (no MTX) Base strategy 140,000 40,000 35,000 53,000
Etanercept (no MTX) of DMARDs 47,000 a 24,000 30,000 a 49,000
Adalimumab (with MTX) with no TNF 64,000 30,000 30,000 170,000
Etanercept (with MTX) inhibitors 50,000 a 24,000 28,000 78,000
Infliximab (with MTX) 140,000 a 38,000 30,000 650,000
a Reflecting current practice.
Base case-results
Results were obtained with base-case parameters
for each of the strategy sets described above.
Single TNF inhibitor use
The base-case ICERs are summarised in Table 50.
The full individual results for each single TNF
inhibitor, used alone or with methotrexate, for
each strategy are given in Tables 51–54.
For the HAQ improvement on starting a TNF
inhibitor, the ‘early RA’ values were used for the
strategy set involving TNF inhibitors at the start,
both sets of values were used for single TNF
inhibitors in third place, and the ‘late RA’ values
were used for all other cases. When interpreting
these results, it should be borne in mind that the
distinction between early RA and late RA is rather
arbitrary and is not always practical. Of note,
patients’ response to a drug or to a combination
of drugs depends on their previous experience
with these therapies. Patients’ previous
experience with methotrexate is particularly
relevant here: the early RA data used in our model
represent the benefit that would be expected if the
patients were naïve to methotrexate or had not
previously failed methotrexate treatment. The
analyses using early RA data in the strategies
involving TNF inhibitors combined with
methotrexate as third line therapy are therefore
better interpreted as sensitivity analyses that
incorporated treatment benefit that is unlikely
to be seen in current practice (as most patients, if
not all, would have failed methotrexate before
starting a TNF inhibitor as the third line
treatment, according to current guidance). For
TNF inhibitors used alone, the cost-effectiveness
of current practice probably lies between the
results in which early RA data and late RA data
were used.
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