Cost-Effectiveness Modelling of Sequential Biologic Strategies for the Treatment of Moderate to Severe Rheumatoid Arthritis in Finland

K Puolakka1, H Blåfield2, M Kauppi3, R Luosujärvi4, R Peltomaa4, T Leikola-Pelho5, K Sennfalt6, A Beresniak*, 7, 8
1 Lappeenranta Central Hospital, Lappeenranta, Finland
2 Seinäjoki Central Hospital, Seinäjoki, Finland
3 Rheumatism Foundation Hospital, Heinola, Finland
4 Helsinki University Central Hospital, Helsinki, Finland
5 Bristol-Myers Squibb, Helsinki, Finland
6 Bristol-Myers Squibb, Stockholm, Sweden
7 Data Mining International, Geneva, Switzerland
8 Paris-Descartes University, Paris, France

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© Puolakka et al.; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

* Address correspondence to this author at the Data Mining International, Route de l’Aéroport, 29-31, Case Postale 221, CH-1215 Geneva 15, Switzerland; Tel: + 41 22 799 34 00; Fax: + 41 22 788 38 50; E-mail:



The main objective was to compare the cost-effectiveness of therapeutic options in moderate or severe rheumatoid arthritis (RA) when a clinical response to a first TNF-blocker, either etanercept (ETA), adalimumab (ADA), or infliximab (INF), is insufficient.


Effectiveness criteria were defined as remission (RS), low disease activity (LDAS), and moderate to high disease activity (MHDAS). Cost-effectiveness was derived as cost per day in RS and in LDAS using simulation modelling to assess six sequential biologic strategies over 2 years. Each sequential treatment strategy was composed of three biologic agents and included a first anti-TNF agent, ETA, ADA or INF, followed by either abatacept (ABA) or rituximab (RTX) as a second therapeutic option in case of an insufficient response, followed by another anti-TNF agent in case of further insufficient response.


Over two years and taking into account biologic costs, the following estimated mean costs per day in RS and LDAS were respectively of €829 and €428 for the biologic sequence composed of ADA-ABA-ETA, €1292 and €516 for the sequence ADA-RTX-ETA, €829 and €429 for the sequence ETA-ABA-ADA, €1292 and €517 for the sequence ETARTX- ADA, €840 and €434 for the sequence INF-ABA-ETA, and €1309 and €523 for the sequence INF-RTX-ETA.


The treatment sequences including ABA as the second biologic option appear more cost-effective than those including RTX in a patients with moderate to severe RA and an insufficient response to a first anti-TNF agent.

Keywords: Cost-effectiveness, rheumatoid arthritis, biologics, modelling..