Improvement at Any Cost? The Art and Science of Choosing Treatment Strategies for Rheumatoid Arthritis
Authors: Elena Losina, Jeffrey N. Katz
Journal: Annals of Internal Medicine (2017)

Editorials4 July 2017Improvement at Any Cost? The Art and Science of Choosing Treatment Strategies for Rheumatoid ArthritisElena Losina, PhD and Jeffrey N. Katz, MD, MScElena Losina, PhDFrom Brigham and Women's Hospital, Boston, Massachusetts. and Jeffrey N. Katz, MD, MScFrom Brigham and Women's Hospital, Boston, Massachusetts.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M17-1176 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Rheumatoid arthritis (RA) is a chronic inflammatory disease that typically involves several upper- and lower-extremity joints. Three decades ago, treatment was guided by a step-up approach that started with nonsteroidal anti-inflammatory drugs and other conservative measures and moved to more potent and potentially toxic drugs if symptoms persisted or evidence of structural damage emerged. Since then, RA treatment has advanced dramatically. The routine use of conventional disease-modifying antirheumatic drugs (cDMARDs), such as methotrexate, enabled clinicians to better control RA symptoms and slow the destruction of cartilage and bone. Research showing that early structural changes portend poor prognosis (1), coupled with ...References1. Baker JF, Ostergaard M, Emery P, Hsia EC, Lu J, Baker DG, et al. Early MRI measures independently predict 1-year and 2-year radiographic progression in rheumatoid arthritis: secondary analysis from a large clinical trial. Ann Rheum Dis. 2014;73:1968-74. [PMID: 23904470] doi:10.1136/annrheumdis-2013-203444 CrossrefMedlineGoogle Scholar2. Smolen JS, Landewé R, Breedveld FC, Dougados M, Emery P, Gaujoux-Viala C, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis. 2010;69:964-75. [PMID: 20444750] doi:10.1136/ard.2009.126532 CrossrefMedlineGoogle Scholar3. van Vollenhoven RF, Chatzidionysiou K. Rheumatoid arthritis. Triple therapy or etanercept after methotrexate failure in RA? Nat Rev Rheumatol. 2013;9:510-2. [PMID: 23897440] doi:10.1038/nrrheum.2013.118 CrossrefMedlineGoogle Scholar4. O'Dell JR, Mikuls TR, Taylor TH, Ahluwalia V, Brophy M, Warren SR, et al; CSP 551 RACAT Investigators. Therapies for active rheumatoid arthritis after methotrexate failure. N Engl J Med. 2013;369:307-18. [PMID: 23755969] doi:10.1056/NEJMoa1303006 CrossrefMedlineGoogle Scholar5. Ng B, Chu A, Khan MM. A retrospective cohort study: 10-year trend of disease-modifying antirheumatic drugs and biological agents use in patients with rheumatoid arthritis at Veteran Affairs Medical Centers. BMJ Open. 2013;3. [PMID: 23562815] doi:10.1136/bmjopen-2012-002468 CrossrefMedlineGoogle Scholar6. Bansback N, Phibbs CS, Sun H, O'Dell JR, Brophy M, Keystone EC, et al; CSP 551 RACAT Investigators. Triple therapy versus biologic therapy for active rheumatoid arthritis. A cost-effectiveness analysis. Ann Intern Med. 2017;167:8-16. doi:10.7326/M16-0713 LinkGoogle Scholar7. Sanders GD, Neumann PJ, Basu A, Brock DW, Feeny D, Krahn M, et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: Second Panel on Cost-Effectiveness in Health and Medicine. JAMA. 2016;316:1093-103. [PMID: 27623463] doi:10.1001/jama.2016.12195 CrossrefMedlineGoogle Scholar8. Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness—the curious resilience of the $50,000-per-QALY threshold. N Engl J Med. 2014;371:796-7. [PMID: 25162885] doi:10.1056/NEJMp1405158 CrossrefMedlineGoogle Scholar9. Bosmans JE, de Bruijne MC, van Hout HP, Hermens ML, Adèr HJ, van Tulder MW. Practical guidelines for economic evaluations alongside equivalence trials. Value Health. 2008;11:251-8. [PMID: 18380637] doi:10.1111/j.1524-4733.2007.00245.x CrossrefMedlineGoogle Scholar10. Organisation for Economic Co-operation and Development (OECD). Country Note: How Does Health Spending in the United States Compare? OECD Health Statistics 2015. Accessed at www.oecd.org/unitedstates/Country-Note-UNITED%20STATES-OECD-Health-Statistics-2015.pdf on 8 May 2017. Google Scholar Author, Article, and Disclosure InformationAffiliations: From Brigham and Women's Hospital, Boston, Massachusetts.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-1176.Corresponding Author: Elena Losina, PhD, Policy Innovation eValuations in Orthopedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 60 Fenwood Road, BTM 5-016, Boston, MA 02115; e-mail, [email protected]harvard.edu.Current Author Addresses: Drs. Losina and Katz: Policy Innovation eValuations in Orthopedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 60 Fenwood Road, BTM 5-016, Boston, MA 02115.This article was published at Annals.org on 30 May 2017. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoTriple Therapy Versus Biologic Therapy for Active Rheumatoid Arthritis Nick Bansback , Ciaran S. Phibbs , Huiying Sun , James R. O'Dell , Mary Brophy , Edward C. Keystone , Sarah Leatherman , Ted R. Mikuls , Aslam H. Anis , and Metrics Cited bySustained Intra-Articular Release and Biocompatibility of Tacrolimus (FK506) Loaded Monospheres Composed of [PDLA-PEG1000]-b-[PLLA] Multi-Block Copolymers in Healthy Horse JointsTherapeutic Options and Cost-Effectiveness for Rheumatoid Arthritis TreatmentCost‐Effectiveness of Combination Disease‐Modifying Antirheumatic Drugs Versus Tumor Necrosis Factor Inhibitors in Active Rheumatoid Arthritis: A Pragmatic, Randomized, Multicenter TrialFirst-line biologic not cost effective versus triple therapy for RABiologic therapy more costly than triple therapy for RA 4 July 2017Volume 167, Issue 1Page: 55-56KeywordsBiologicsDisease modifying antirheumatic drugsDrugsHydroxychloroquineMethotrexateOrthopedic surgeryOrthopedicsQuality adjusted life yearsQuestionnairesRheumatoid arthritis ePublished: 30 May 2017 Issue Published: 4 July 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...