Some rheumatologists have argued in recent years that starting on a biologic drug right away is a more effective — and cost-effective — approach to managing rheumatoid arthritis (RA) in its early stages.
But a new study shows this isn’t always the case.
Often people with RA will be prescribed a singular disease-modifying antirheumatic drug (DMARD), or similar immunosuppressive medications early on in the disease process.
These drugs include medications such as methotrexate and azathioprine.
If these meds fail, a doctor will usually go straight to expensive, sometimes risky, biologic drugs, like B cell modifiers, anti-TNF drugs, or JAK inhibitors.
These biologics are often administered via intravenous (IV) infusion or injection, and can be costly to manage and cause a wide array of side effects.
But people with RA have become used to biologics being an automatic part of their RA treatment.
Try triple therapy first?
Some researchers, however, are now advising to wait it out.
They are urging people with RA to first try a “triple therapy” approach before jumping straight to the biologic protocol.
Recent studies have concluded this methodology can be more cost-effective for patients and insurers.
According to a recent press release put out by the American College of Physicians, “Results of a comprehensive cost-effectiveness analysis suggest that patients who have RA and no contraindications to triple therapy should use it prior to a biologic as the next regimen.”
This suggestion is based on a comparative study that was published in the Annals of Internal Medicine earlier this year.
The study, called the Rheumatoid Arthritis Comparison of Active Therapies (RACAT) trial, questioned whether a biologics-first approach was more effective and less expensive in the long run.
Researchers concluded a “triple therapy” combination of more inexpensive drugs like sulfasalazine, hydroxychloroquine, and methotrexate was just as effective as switching directly to the heavy-hitting biologics.
But the study also suggested that not many people with RA, or their doctors, are eager to try this triple-therapy approach instead of biologic drugs.
Show me the money
Those high price tags are worth noting.
The authors of the study explained that treatment with biologic therapy may provide marginally better benefits, but not in an amount that would even be noticeable to most people with RA.
A lifetime analysis suggested a first-line biologic treatment would result in a slight improvement of qualify of life, but that this gain would cost an incremental $77,000.
They added this extra expense would lead to an incremental cost-effectiveness ratio of $521,520 per quality-adjusted life year per patient.
According to the press release, “The authors conclude that patients, unless contraindicated, should switch to triple therapy first before switching to a biologic strategy.”
The authors cited literature showing this is a strategy that many people with RA would prefer since it could reduce their out-of-pocket costs, and would not expose them to the risk of serious side effects associated with biologic medications.
What people with RA think
People with RA seem to have mixed feelings on the issue.
“I would feel more comfortable trying an aggressive approach from the get-go,” Joel Whitehead, a Georgia resident with RA and PsA, told Healthline. “If that means biologics, great. They might cost my insurance company more money, but I feel like I would maybe benefit more in the long run.”
Daisy Thomas, a California resident with juvenile RA, had a different opinion.
“If using a combination of cheaper medications can be just as effective as a biologic, then why not try it?” she told Healthline. “The infusions kind of scare me, and I’ve heard they can have an out-of-pocket expense of over $10,000 a pop. I’d rather take a few pills every day or every week, and pay less money if it’s going to be the same effect anyway.”
As of 2015, people with RA can expect to pay at least $2,700, on average, in copays per year, with some treatments costing upward of $3,000 per month.
A single infusion of Rituxan can be $28,000. A dose of Enbrel can be $1,700.