A systematic review of the effectiveness of adalimumab

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Health economics
TABLE 51 Base case: TNF inhibitors third (late RA values) (40,000 patients)
Option Cost (£) QSE QALYs QSE
Adal 47,442 154 5.6365 0.0234
Etan 60,341 188 6.3415 0.0246
Adal+MTX 47,963 155 5.9053 0.0232
Etan+MTX 60,329 188 6.2974 0.0250
Infl+MTX 47,278 148 5.6380 0.0235
Base 16,509 36 5.4169 0.0218
Comparison Diff. cost (£) QSE Diff. QALY QSE
Adal – Base 30,934 150 0.2196 0.0224
Etan – Base 43,832 181 0.9246 0.0237
Ad+M – Base 31,454 151 0.4884 0.0226
Et+M – Base 43,821 182 0.8805 0.0241
In+M – Base 30,770 145 0.2212 0.0224
Ad+M – Adal 520 204 0.2688 0.0288
Etan – Et+M 12 243 0.0441 0.0252
Etan – Adal 12,899 225 0.7050 0.0238
Et+M – Ad+M 12,367 225 0.3920 0.0242
Ad+M – In+M 684 200 0.2673 0.0228
Et+M – In+M 13,051 221 0.6593 0.0241
Comparison ICER (£ per QALY) Quasi-CI
Adal – Base 141,000 117,000 to 177,000
Etan – Base 47,400 45,100 to 50,000
Ad+M – Base 64,400 58,900 to 71,000
Et+M – Base 49,800 47,200 to 52,700
In+M – Base 139,000 116,000 to 174,000
Ad+M – Adal 1,940 382 to 3,490
Etan – Et+M Comparison is inconclusive
Etan – Adal 18,300 17,000 to 19,800
Et+M – Ad+M 31,500 27,900 to 36,200
Ad+M – In+M 2,560 999 to 4,120
Et+M – In+M 19,800 18,300 to 21,500
QSE, quasi-standard error.
Ad, adalimumab; Et, etanercept; In, infliximab; M, methotrexate.
Sequential use of TNF inhibitors
Sequential use of TNF inhibitors was modelled
with the TNF inhibitors starting as third line
therapy and using the ‘late RA’ values for the TNF
inhibitors. Base-case ICERs are summarised in
Table 55 and the individual results for the
sequential use of TNF inhibitors are given in
Tables 56–64. The results are similar to those using
the ‘Following TNF inhibitor’ as the sole TNF
inhibitor in third place as shown in Table 51,
except that the two other TNF inhibitors are
somewhat less cost-effective if used after
etanercept. Similar results were obtained for TNF
inhibitors as the third in the sequence.
Sensitivity analysis
Extensive sensitivity analysis has been carried out
for all strategy sets involving use of a single TNF
inhibitor. As in the base case, 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, the late RA
values were used for TNF inhibitors last, and both
sets of values were used for TNF inhibitors in
third place. Full details of the sensitivity analysis
are given in Appendix 10. Summarised forms are
given in Tables 65–68.
Summary of model results
When the effectiveness values for early RA were
used for TNF inhibitors in third place, the results
for the three TNF inhibitors were broadly similar.
They are sensitive to assumptions about HAQ
progression while on treatment, and to
assumptions about effectiveness and long-term
survival on conventional DMARDs. When the
effectiveness values for late RA were used instead,
the results were considerably less favourable.