Biological DifferentiationBiological DifferentiationPart IIPart II

Dubai, United Arab EmiratesDubai, United Arab EmiratesJanuary 19th, 2009January 19th, 2009

Prof. Joachim R. KaldenProf. Joachim R. KaldenDirector emeritusDirector emeritus

Dept. of Internal Medicine IIIDept. of Internal Medicine IIIDiv. of Molecular ImmunologyDiv. of Molecular Immunology

Nikolaus-Fiebiger-CenterNikolaus-Fiebiger-CenterUniversity of Erlangen-NurembergUniversity of Erlangen-Nuremberg

OverviewOverview

Value for TNF antagonists in RA Value for TNF antagonists in RA

Economic evaluation for biologics in RAEconomic evaluation for biologics in RA

ENBREL & QoL of RA patientsENBREL & QoL of RA patients

Measurement of RA impactMeasurement of RA impact

Cost-effectiveness of ENBREL vs. biologicsCost-effectiveness of ENBREL vs. biologics

Impact of biologics on QALYImpact of biologics on QALY

What is What is ValueValue for a for a Healthcare Healthcare

Intervention?Intervention?

ValueValue

Does a healthcare intervention save lives Does a healthcare intervention save lives or reduce disease?or reduce disease?

Does the healthcare intervention save cost Does the healthcare intervention save cost in a health system?in a health system?

Does the healthcare intervention get Does the healthcare intervention get people back to normal living or work?people back to normal living or work?

Does the healthcare intervention do all the Does the healthcare intervention do all the above better than the existing therapies?above better than the existing therapies?

ValueValueValue = • [cost][benefit]

CostCost AcquisitionAcquisition Delivery Delivery TrainingTraining MonitoringMonitoring Cost to patientCost to patient

TravelTravel Time off workTime off work

Adverse eventsAdverse events Healthcare professional visitsHealthcare professional visits State benefitsState benefits Lost taxesLost taxes Productivity lossProductivity loss

BenefitBenefit

ClinicalClinical Reduced number active Reduced number active

jointsjoints Reduced damageReduced damage Reduced mortalityReduced mortality Reduced cardiovascular Reduced cardiovascular

eventsevents Reduced osteoporosisReduced osteoporosis Reduced fatigueReduced fatigue

Quality of lifeQuality of life Reduced disabilityReduced disability Reduced depressionReduced depression Improved work outputImproved work output Improved social lifeImproved social life

Intangible benefitsIntangible benefits

Need to Communicate with Need to Communicate with PayorsPayors Competitive world - we must be advocates Competitive world - we must be advocates

for our patients for healthcare resource!!for our patients for healthcare resource!! ““Key” areas - cardiology, oncology etc etcKey” areas - cardiology, oncology etc etc New expensive drugs hitting the market in New expensive drugs hitting the market in

“key” areas“key” areas Still major unmet need for rheumatology Still major unmet need for rheumatology

patientspatients Make sure that rheumatology maintains its Make sure that rheumatology maintains its

“share of voice” “share of voice” Built on a principle of large amounts of good Built on a principle of large amounts of good

data in many countries examining the impact data in many countries examining the impact of these agents over the last 5 yearsof these agents over the last 5 years

Treatment with TNF-Treatment with TNF-blockers and mortality risk blockers and mortality risk in patients with rheumatoid in patients with rheumatoid

arthritisarthritis

ObjectiveObjective

To assess mortality in patients with RA treated with To assess mortality in patients with RA treated with TNF inhibitors, compared to a standard RA TNF inhibitors, compared to a standard RA population.population.

921 RA patients started on TNF inhibitors in 1999 or 921 RA patients started on TNF inhibitors in 1999 or later recruited from regional register of RA patients later recruited from regional register of RA patients to cohort.to cohort.

Patient and disease characteristics including HAQ Patient and disease characteristics including HAQ scores gathered from regional register.scores gathered from regional register.

Total cohort linked to national register for cause of Total cohort linked to national register for cause of death.death.

Overall mortality rates in those treated with TNF Overall mortality rates in those treated with TNF inhibitors compared to those not treated with TNF inhibitors compared to those not treated with TNF inhibitors estimated using standardised mortality inhibitors estimated using standardised mortality ratios (SMRs).ratios (SMRs).

ResultsResults

SMR (or SMR ratio) at follow up (95% CI)SMR (or SMR ratio) at follow up (95% CI)

2 years2 years 3 years3 years 4 years4 years

Anti-TNF exposed Anti-TNF exposed

(n = 921)(n = 921)

AllAll 1.2 (0.64-1.75)1.2 (0.64-1.75) 1.20 (0.74-1.20 (0.74-1.75)1.75)

1.50 (1.03-1.50 (1.03-1.96)1.96)

MenMen 1.65 (0.57-1.65 (0.57-2.74)2.74)

1.79 (0.85-1.79 (0.85-2.72)2.72)

1.86 (1.00-1.86 (1.00-2.72)2.72)

WomenWomen 0.94 (0.33-0.94 (0.33-1.55)1.55)

0.88 (0.38-0.88 (0.38-1.37)1.37)

1.29 (0.75-1.29 (0.75-1.83)1.83)

Non Anti-TNF Non Anti-TNF exposed exposed

(n = 652)(n = 652)

AllAll 1.51 (0.99-1.51 (0.99-2.04)2.04)

1.54 (1.11-1.54 (1.11-1.96)1.96)

1.50 (1.14-1.50 (1.14-1.86)1.86)

MenMen 1.18 (0.45-1.18 (0.45-1.90)1.90)

1.24 (0.63-1.24 (0.63-1.85)1.85)

1.19 (0.68-1.19 (0.68-1.701.70

WomenWomen 1.74 (1.01-1.74 (1.01-2.47)2.47)

1.73 (1.15-1.73 (1.15-2.31)2.31)

1.70 (1.21-1.70 (1.21-2.19)2.19)

SMR ratio SMR ratio

(anti-TNF exposed (anti-TNF exposed vs not exposed)vs not exposed)

AllAll 0.79 (0.42-0.79 (0.42-1.44)1.44)

0.78 (0.47-0.78 (0.47-1.27)1.27)

1.00 (0.66-1.00 (0.66-1.49)1.49)

MenMen 1.41 (0.51-1.41 (0.51-4.04)4.04)

1.44 (0.65-1.44 (0.65-3.16)3.16)

1.56 (0.78-1.56 (0.78-3.05)3.05)

WomenWomen 0.54 (0.22-0.54 (0.22-1.22)1.22)

0.50 (0.24-0.50 (0.24-0.99)0.99)

0.76 (0.44-0.76 (0.44-1.28)1.28)

Mortality ratios generated using Swedish national data as reference.Mortality ratios generated using Swedish national data as reference.

TNF inhibitor treated patients appear to have reduced SMR compared TNF inhibitor treated patients appear to have reduced SMR compared to those not treated with TNF inhibitors.to those not treated with TNF inhibitors.

ConclusionsConclusions

Critical role for inflammation in RA Critical role for inflammation in RA associated premature mortalityassociated premature mortality

Anti-TNF therapy may reduce mortality in Anti-TNF therapy may reduce mortality in RARA

Reductions in Healthcare Reductions in Healthcare Resource UseResource Use

Importance of Resource Use Importance of Resource Use ReductionReduction

Traditional Model Traditional Model (HTA): What does (HTA): What does the net cost of drug the net cost of drug buy you in health buy you in health benefits?benefits?

Emerging Model Emerging Model (Policy Model): Can (Policy Model): Can help shape policy by help shape policy by alleviating payors’ alleviating payors’ budgetary concernsbudgetary concerns

Pre-treatm

ent

Co

st of C

are

Po

st-treatmen

tC

ost o

f Care

Net Cost

Cost Offsets

Drug Costs

To

tal

Co

st o

f C

are

Pre – TreatmentTotal cost of Care

Post – TreatmentTotal cost of Care

Use of TNF therapy associated Use of TNF therapy associated with a decline in resource Usewith a decline in resource Use

Subjects on etanercept or infliximab (Mar99 to Jun00)Subjects on etanercept or infliximab (Mar99 to Jun00)

Four rheumatology centers in Helsingborg, Kristianstad, Four rheumatology centers in Helsingborg, Kristianstad, Trelleborg, and Lund (n=116)Trelleborg, and Lund (n=116)

Pre – Post comparison implemented at 12 monthsPre – Post comparison implemented at 12 months

Pre - Post Anti-TNF Treatment

857

593

332

113

0

200

400

600

800

1000

Surgery-RelatedHospitalization

Non-SurgeryHospitalization

To

tal

Nu

mb

er o

f D

ays

Pre - Post Anti-TNF Treatment

56

22 2028

10 8

0

10

20

30

40

50

60

OrthopaedicProcedures

Major JointReplacement

Hand Surgery

Per

cen

t P

er P

atie

nt

Yea

r

Kobelt et al :Annals of the Rheumatic Diseases 2004;63:4-10

Biologics have a Biologics have a profound effect on the profound effect on the

quality of life of patients quality of life of patients with RAwith RA

ACR Responses ACR Responses (LOCF): TEMPO(LOCF): TEMPO

*P<0.05, E versus MTX†P<0.05, combination versus MTX‡P<0.05, combination versus E

*

ACR 20 ACR 50 ACR 70

months

86† 85†‡

69†‡ 71†‡ 67†‡

43†‡49†‡ 49†‡

85

0

20

40

60

80

100

12 24 36 12 24 36 12 24 36

% o

f P

atie

nts

MTX E MTX+E

TEMPO. Data on file. Wyeth.

HAQ Values (LOCF)HAQ Values (LOCF)

† P<0.05, combination vs MTX‡ P<0.05, combination vs E

0

1

2

0 3 6 9 12 15 18 21 24 27 30 33 36

Months

Mea

n V

alu

e

MTX E MTX+E

1.1

1.1

0.8†‡

†‡ †‡ †‡ †‡ †† †

†‡ † †‡ †‡

TEMPO. Data on file. Wyeth.

Adalimumab (PREMIER): Adalimumab (PREMIER): 52 and 104 weeks52 and 104 weeks

*P<0.001 for adalimumab + MTX vs MTX alone and adalimumab alone# P=0.043 for MTX vs adalimumab, others NS

% p

atie

nts

0

10

20

30

40

50

60

70

80

ADA +MTX

ADA MTX

ACR20

7369

5450

6356

#

**

0

10

20

30

40

50

60

70

80

ADA+MTX

ADA MTX

ACR50

6259

4237

4643

* *

0

10

20

30

40

50

60

70

80

ADA+MTX

ADA MTX

ACR70

46 47

26 28 28 28

* *

Week 52

Week 104

How Can We Measure How Can We Measure the impact of RA the impact of RA

at Home and Work?at Home and Work?

Impact of RA on Work Impact of RA on Work Disability?Disability? Work loss is common in RAWork loss is common in RA

Approximately 25% to 50% of patients with RA stop working Approximately 25% to 50% of patients with RA stop working within a decade of disease onsetwithin a decade of disease onset

Between 50% and 90% stop working before age 65Between 50% and 90% stop working before age 65

Economic evaluation of impact on workEconomic evaluation of impact on work Employment to unemploymentEmployment to unemployment Missed days of work (Absenteeism)Missed days of work (Absenteeism) Productivity loss (Presenteeism)Productivity loss (Presenteeism) Changing occupationChanging occupation

Several factors contribute to work lossSeveral factors contribute to work loss Biopsychosocial – support structure, type of job (white vs. blue Biopsychosocial – support structure, type of job (white vs. blue

collar; management vs. clerical), educationcollar; management vs. clerical), education Economic incentive and disincentive to workEconomic incentive and disincentive to work Clinical factors: joint damage, pain, fatigue, sleep lossClinical factors: joint damage, pain, fatigue, sleep loss Missed days of work is important marker of future work lossMissed days of work is important marker of future work loss

Work ability and disability in Work ability and disability in rheumatologyrheumatology Patients with RA have reduced productivity, Patients with RA have reduced productivity,

increased lost work days and retire earlyincreased lost work days and retire early Systematic review (Burton et al 2006): 66% of Systematic review (Burton et al 2006): 66% of

RA patients experienced work loss in previous RA patients experienced work loss in previous 12 months with median duration of 39 days12 months with median duration of 39 days

Approximately one third of RA patients stop Approximately one third of RA patients stop work earlywork early

Begins early after onsetBegins early after onset In FIN-RACo in first 5 yrs of disease (Puolakka et In FIN-RACo in first 5 yrs of disease (Puolakka et

al, ARD 2006):al, ARD 2006): 75% lose work days 75% lose work days Mean productivity loss per year (human capital) €7217Mean productivity loss per year (human capital) €7217 Work loss related to HAQ and increasing erosionsWork loss related to HAQ and increasing erosions

Effect of TNF inhibitorsEffect of TNF inhibitors

RAPOLO results (Yelin et al A&R 2003)RAPOLO results (Yelin et al A&R 2003) Compared cohort taking etanercept with control RA groupCompared cohort taking etanercept with control RA group Patients receiving etanercept worked on average 7.4 h more Patients receiving etanercept worked on average 7.4 h more

per weekper week

Canadian study (Farahani et al, J Rheumatol, 2006)Canadian study (Farahani et al, J Rheumatol, 2006) Compared cohort taking etanercept with control RA group Compared cohort taking etanercept with control RA group In 1st 6m, lost work days significantly less in etanercept than In 1st 6m, lost work days significantly less in etanercept than

control group 2.5d v 7.8d (control group 2.5d v 7.8d (PP=0.03). Difference not significant at =0.03). Difference not significant at 12 months12 months

Days with reduced productivity significantly less in etanercept Days with reduced productivity significantly less in etanercept than control group at both 6 and 12 months (32.9 v 45.8; 60.7 v than control group at both 6 and 12 months (32.9 v 45.8; 60.7 v 86.5, both 86.5, both PP=0.02)=0.02)

Impact on Current Impact on Current EmploymentEmployment

Probability of Current Employment Among Enbrel/non-Enbrel Users (%)

(n=497)

Unadjusted

Adjusted ForDemographics,

RA Status, Occupation,

Industry

Diff = 16%(95% CI 7-26%)

Diff = 20%(95% CI 9-32%)72

71

54

55

0 20 40 60 80

RAPOLO (n=238) RA Panel (n=259)

Yelin Ed et al. A&R 2003:48(11):3046-54

Improvement in PresenteeismImprovement in Presenteeism

27.8

26.8

21.4

20.4

0 10 20 30

RAPOLO (n=238) RA Panel (n=259)

Quantity of Current Employment (hours/week), Among All Employed At Diagnosis

(n=497)

Unadjusted

Adjusted ForDemographics,

RA Status, Occupation,

Industry

Diff = 5.4(95% CI 1.1, 9.7)

Diff = 7.4(95% CI 2.6, 12.3)

Yelin Ed et al. A&R 2003:48(11):3046-54

P<0.0001

P<0.0001

P<0.0001

P<0.0001

Reduction in AbsenteeismReduction in Absenteeism

RADIUS 2: long-term US registry RADIUS 2: long-term US registry of adults patients with RA who of adults patients with RA who initiated or added etanercept to initiated or added etanercept to their treatment at enrollmenttheir treatment at enrollment

Enrolled 5,000 patients from Enrolled 5,000 patients from both academic & community both academic & community practicespractices

For patients who reported that For patients who reported that they were employed in some they were employed in some way at baseline, the number of way at baseline, the number of missed workdays was missed workdays was analysedanalysed

Monotherapy

1.64

0.72 0.83

0

0.4

0.8

1.2

1.6

2

2.4

Baseline(n=596)

6 months(n=577)

12 months(n=596)

Mea

n #

of

Tim

es M

isse

d W

ork

fo

r H

alf

a D

ay o

r M

ore

in P

rio

r M

on

th

0

0.4

0.8

1.2

1.6

2

2.4

1.43

0.660.83

0

0.4

0.8

1.2

1.6

2

2.4

Baseline(n=895)

6 months(n=875)

12 months(n=596)

Combination

Me

an

# o

f T

ime

s M

iss

ed W

ork

fo

r H

alf

a D

ay

or

Mo

re i

n P

rio

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on

th

Gibofsky A et al. Curr Med Res Opin 2006;22:169-83.

Reduction in Need to Seek Less Reduction in Need to Seek Less Demanding JobDemanding Job

For patients who For patients who reported that they reported that they were employed at were employed at baseline, the number baseline, the number of missed workdays of missed workdays was analysedwas analysed

Montherapy

28.5

15 14.7

0

5

10

15

20

25

30

35

40

Baseline (n=463) 6 months(n=446)

12 months(n=463)

% o

f P

atie

nts

wh

o h

ad t

o t

ake

a le

ss

ph

ysic

ally

dem

and

ing

job

P<0.0001

P<0.0001

Montherapy

28.5

15 14.7

0

5

10

15

20

25

30

35

40

Baseline (n=463) 6 months(n=446)

12 months(n=463)

% o

f P

atie

nts

wh

o h

ad t

o t

ake

a le

ss

ph

ysic

ally

dem

and

ing

job

Combination

28.3

14.6 14.6

0

5

10

15

20

25

30

35

40

Baseline (n=685) 6 months(n=666)

12 months(n=685)

% o

f P

atie

nts

wh

o h

ad t

o t

ake

a le

ss

ph

ysic

ally

dem

and

ing

job

P<0.0001P<0.0001

Combination

28.3

14.6 14.6

0

5

10

15

20

25

30

35

40

Baseline (n=685) 6 months(n=666)

12 months(n=685)

% o

f P

atie

nts

wh

o h

ad t

o t

ake

a le

ss

ph

ysic

ally

dem

and

ing

job

Gibofsky A et al. Curr Med Res Opin 2006;22:169-83.

Pharmacoeconomic Pharmacoeconomic evaluations - why evaluations - why

bother…?bother…?

Pharmacoeconomic evaluations - Pharmacoeconomic evaluations - why bother…?why bother…?

Resources are scarceResources are scarce People, time, facilities, equipment, knowledgePeople, time, facilities, equipment, knowledge

Medications are expensiveMedications are expensive Over 20 therapies with cost > $4000 per yearOver 20 therapies with cost > $4000 per year

Assists in making the decision process Assists in making the decision process explicitexplicit Can take into account preferences and Can take into account preferences and

attributesattributes

How can we measure How can we measure cost-effectiveness of cost-effectiveness of

drugs?drugs?

Rheumatoid Arthritis Rheumatoid Arthritis Health Economics MethodologyHealth Economics Methodology

Models based on DMARD and biologic sequences Models based on DMARD and biologic sequences being compared over a period beyond clinical trial being compared over a period beyond clinical trial timeframestimeframes

Lifetime of disease model often taken to reflect Lifetime of disease model often taken to reflect chronicity of disease, time of diagnosis, and age chronicity of disease, time of diagnosis, and age profile of patientsprofile of patients

Majority of models now have incremental cost per Majority of models now have incremental cost per quality adjusted life year as primary outcome quality adjusted life year as primary outcome measuremeasure

Cost per QALY is derived from relationship between Cost per QALY is derived from relationship between change in HAQ and QoL from observational databaseschange in HAQ and QoL from observational databases

HTA bodies make economic analysis comparisons HTA bodies make economic analysis comparisons based on analysis of data from key clinical trialsbased on analysis of data from key clinical trialsN.B. Data on “real world use” of TNFs not counted in costs in economic analysis

– no account of dose change taken into account

Quality Adjusted Life Years Quality Adjusted Life Years (QALY)(QALY) QALY: composite measure of quality and quantity of QALY: composite measure of quality and quantity of

lifelife

Health benefit of a healthcare interventionHealth benefit of a healthcare intervention Reduced mortality, and/orReduced mortality, and/or Improved healthImproved health

QALY used because it allows comparisons across QALY used because it allows comparisons across diseases and interventionsdiseases and interventions

QALY support decision on healthcare resourcesQALY support decision on healthcare resources

Best use of limited resources: Best use of limited resources: Fund interventions that offer more QALYs for marginal unit of Fund interventions that offer more QALYs for marginal unit of

money spentmoney spent Thresholds for cost-effectivenessThresholds for cost-effectiveness

US: $50-100K for an incremental QALYUS: $50-100K for an incremental QALY UK: UK: £30k for an incremental QALY£30k for an incremental QALY

Value FrameworkValue FrameworkAn Illustration of QALYsAn Illustration of QALYs

1 QALY

UTILITY VALUE

0

1.0

YEARS

4

0.5

21

1 QALY

Gain= 1 QALY

Gains from MortalityBenefits

Gain =1 QALYGains from QoLBenefits

Independent Cost Effectiveness Review Independent Cost Effectiveness Review Latest Results from NICE Appraisal – Nov 2006Latest Results from NICE Appraisal – Nov 2006

TNF Cost Effectiveness calculated after 2 DMARD failuresin combination with MTX

Late RA dataLate RA data Early RA dataEarly RA data

HAQ HAQ progressionprogression

No HAQ No HAQ progressioprogressionn

HAQ HAQ progressioprogressionn

No HAQ No HAQ progressionprogression

adalimumaadalimumabb £64,000£64,000 £30,200£30,200 £30,200£30,200

etanerceptetanercept £49,800£49,800 £24,600£24,600 £28,500£28,500 >£20,000>£20,000

infliximabinfliximab £139,000£139,000 £39,400£39,400 £30,400£30,400

What do you do when a What do you do when a patient fails a TNF patient fails a TNF

Inhibitor? Inhibitor? Switching to a Switching to a different TNF different TNF

antagonist or to any antagonist or to any other available biologicother available biologic

Independent Cost Effectiveness Review Independent Cost Effectiveness Review Latest Results from NICE Appraisal – Nov 2006Latest Results from NICE Appraisal – Nov 2006

‘‘Speculative’ analysis carried out to explore possible bias from Speculative’ analysis carried out to explore possible bias from using mix of RCT & observational data in the model using mix of RCT & observational data in the model

Analysis based on data from RCTs of TNFα inhibitor monotherapy Analysis based on data from RCTs of TNFα inhibitor monotherapy in the cases of adalimumab and etanercept and combination in the cases of adalimumab and etanercept and combination therapy in the case of infliximab therapy in the case of infliximab

In the analysis it was assumed that effectiveness was reduced by In the analysis it was assumed that effectiveness was reduced by 30% to reflect the lesser effectiveness of a second TNFα inhibitor 30% to reflect the lesser effectiveness of a second TNFα inhibitor as seen in the BSRBR as seen in the BSRBR

Estimates of incremental cost effectiveness: ~ £30,000 per QALY Estimates of incremental cost effectiveness: ~ £30,000 per QALY when etanercept used as a second TNFα inhibitor and ~£50,000 when etanercept used as a second TNFα inhibitor and ~£50,000 per QALY when adalimumab and infliximab used as a second TNF per QALY when adalimumab and infliximab used as a second TNF α inhibitor α inhibitor

Cost Effectiveness of Cost Effectiveness of Sequential Use vs Standard Sequential Use vs Standard DMARD SequenceDMARD Sequence

Sequence ICER (£/QALY)

ETN+MTX IFX+MTX £15,495

ETN+MTX ADL+MTX £22,749

IFX+MTX ETN+MTX £15,950

ADL+MTX ETN+MTX £24,455

MTX ETN+MTX IFX+MTX £16,697

MTX ETN+MTX ADL+MTX £17,409

MTX IFX+MTX ETN+MTX £15,211

MTX ADL+MTX ETN+MTX £19,158

Cost Effectiveness Analysis NICE 2006

ConclusionConclusion

Independent UK HTA review has calculated Independent UK HTA review has calculated etanercept as the most cost effective TNF etanercept as the most cost effective TNF agentagent

It is cost effective to prescribe an anti TNF It is cost effective to prescribe an anti TNF after another TNF has failedafter another TNF has failed

Etanercept has beneficial cost effectiveness Etanercept has beneficial cost effectiveness profile when used as a switch agentprofile when used as a switch agent

Etanercept also has beneficial cost Etanercept also has beneficial cost effectiveness profile vs Rituximab in TNF effectiveness profile vs Rituximab in TNF failurefailure

Ongoing studies will further elucidate the real Ongoing studies will further elucidate the real life costs of different biologicslife costs of different biologics

Future developmentsFuture developments

TNF blockersTNF blockers

1.1. Reduce time off work?Reduce time off work?

2.2. Improve quality of work?Improve quality of work?

3.3. Reduce other heath care costs?Reduce other heath care costs?

4.4. Reduce mortality in women?Reduce mortality in women?

5.5. All of these?All of these?

In RA - it is cost effective toIn RA - it is cost effective to

1.1. Withhold TNF inhibitors totally and only use Withhold TNF inhibitors totally and only use low cost drugs?low cost drugs?

2.2. Revert back to a DMARD after 1 TNF inhibitor Revert back to a DMARD after 1 TNF inhibitor failure?failure?

3.3. Swap TNF inhibitor if first agent fails?Swap TNF inhibitor if first agent fails?

4.4. Maintain patients on TNF inhibitors when no Maintain patients on TNF inhibitors when no clinical response?clinical response?

5.5. Allow orthopaedic surgeons to fully manage Allow orthopaedic surgeons to fully manage disease?disease?

SummarySummary

Limited resources for healthcareLimited resources for healthcare

Arthritis often seen as low priorityArthritis often seen as low priority

Biologic therapies most effective in RABiologic therapies most effective in RA

We must argue for our pts!We must argue for our pts!

TNF inhibitors cost effectiveTNF inhibitors cost effective Early diseaseEarly disease More advanced diseaseMore advanced disease To swap after 1 TNF inhibitor failureTo swap after 1 TNF inhibitor failure Cost-effectiveness measures Cost-effectiveness measures further with further with experienceexperience

Payors make the big choices - we must use the Payors make the big choices - we must use the increasing ammunition of evidence to support our increasing ammunition of evidence to support our patientspatients