Ankylosing spondylitis (AS) is the most frequent prototype of spondyloarthritides. Substantial direct costs and productivity losses often arise in young patients. Currently, tumor necrosis factor (TNF) inhibitors are the only approved therapy escalation when usual care (physiotherapy and NSAIDs) proves to be insufficient. Owing to their high medication costs, TNF inhibitors are a target of cost-effectiveness analyses. There is consistent evidence regarding the use of TNF inhibitors according to recommendations in patients with active AS finding TNF inhibitors to be cost effective from a societal perspective. However, there are relevant uncertainties (discontinuation rate and progression rate) in the long-term estimates of the cost-effectiveness analyses analyzed. Whether TNF inhibitors are cost effective from an insurance perspective in the long run will have to be addressed by models based on observational data.
[Show abstract][Hide abstract] ABSTRACT: Introduction: This study investigated the effectiveness of combining reduced tumor-necrosis-factor alpha inhibitor therapy (TNFi) with physical therapy in active spondyloarthritis and its potential cost effectiveness.
Methods: Patients, which fulfilled the Assessment of SpondyloArthritis International Society (ASAS) criteria for classification of axial spondyloarthritis and presented with a Bath Ankylosing Spondylitis Activity Index (BASDAI) of greater than 4 were considered for this six-month proof-of-concept study. Patients were asked to participate in physical therapy sessions either at the hospital or at cooperating physical therapy practices. Etanercept (ETC) was administered weekly in a reduced dosage of 25mg subcutaneously for six month and was combined with intensive physiotherapy sessions of 30 minutes three times a week for 4 month, followed by an observational period of 2 months without physiotherapy, but continued low-dose ETC therapy.
Results: A significant decrease of BASDAI was observed after 16 weeks of combination therapy (n=20; median 6.0 vs. 3.2; IQR 5.1-6.7, 2.4-4.8 respectively; p<0.0001). No difference was seen after 16 weeks for patients treated at the hospital or at participating physiotherapy practices (median BASDAI 2.95 vs. 3.28; IQR 1.2-4.3, 2.25-6.25 respectively; p=0.1902). A simplified calculation estimated a total saving of the combination therapy compared to full-dose ETC therapy of approximately 76,000€ for all patients during the study period.
Conclusions: The results of the study show that intensive physiotherapy could serve as a substitute for a reduced dosage of TNFi for patients with active spondylarthritis. Therefore, combination therapy of low-dose ETC with physical therapy could be a cost-effective alternative for patients with active spondyloarthritis.
The Journal of Rheumatology 09/2014; 41(9):1897-8. DOI:10.3899/jrheum.131431 · 3.19 Impact Factor
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