I felt the need to write this follow up post.
If both are similarly effective (it's debatable which types of patients this statement applies to), we really should be using the cheaper alternative much more.
If both were similarly priced, I don't think we'd be having this debate. I'm guessing most rheumatologists would choose the biologic/Methotrexate combo.
Wouldn't it be good then if the price differential reduces?This will occur. I don't know how quickly or how much, but these are some ways:
The rise of Biosimilars: patents for biologic DMARDs are expiring.
While these are difficult medications to copy due to their molecular size and the complexity of manufacture, there are medications being reverse engineered to look like and act like the original. Already, there are biosimilars for Infliximab, Etanercept and Rituximab.
As these enter the market, I've heard estimates of 30%+ reduction in price.
Use biologic DMARDs earlier in strategies that allow cessation of the biologic
We may one day be allowed to use the biologic/Methotrexate combination upfront with a plan once the rheumatoid arthritis is well controlled to then stop using the biologic and hopefully keep disease control using the cheaper medication.
The OPTIMA trial is an example of this. Rheumatoid patients with early disease (<1 year & naive to Methotrexate, and this may be a key point) were given Adalimumab/Methotrexate. After 26 weeks, roughly half of those who had good disease control had the Adalimumab stopped. At the end of the study after 78 weeks, the outcomes were similar between the group that stopped Adalimumab and the group that stayed on it.
Reduction of the dose of biologic DMARDs
Once patients achieve good control of their disease, some rheumatologists and some patients may reduce either the amount of biologic medication being given. This leads to flare in some but in others, disease control remains good. There is limited trial data for this approach but it's a strategy likely to be explored.
Lower dose means less costs. Less frequent administration means less costs.
The PRESERVE trial is an example of this. The patient population was different to the OPTIMA trial, with later disease, and persistent, uncontrolled disease despite Methotrexate use. Rheumatoid patients who received a low disease activity score on the Etanercept 50mg weekly/Methotrexate combination were then randomised to one of three treatment groups: 50 mg Etanercept/Methotrexate, 25 mg Etanercept/Methotrexate, or placebo/Methotrexate.
The 2 groups using Etanercept, both the conventional & the reduced dose, maintained disease control better that the Methotrexate only group. The outcomes for the 2 different doses of Etanercept were about the same.
Thanks for all the comments regarding this topic on twitter and this forum. Please do continue to share your thoughts.