OP0299 Cost-effectiveness of tapering tnf blockers versus conventional synthetic dmards in rheumatoid arthritis: first year results of the randomised controlled tara-study
Authors: E. van Mulligen, A. E. A.M. Weel, T.M. Kuijper, J.J. Luime, J.M.W. Hazes, P.H.P. de Jong
Journal: Annals of the Rheumatic Diseases (2018)

<h3>Background</h3> Current guidelines recommend to consider tapering treatment in rheumatoid arthritis (RA) patients who are in sustained remission, but the optimal approach to de-escalate conventional synthetic and biological DMARDs (respectively csDMARDs and bDMARDs) remains unknown. The benefits of tapering are a decreased risk of long-term adverse events and a reduction of health care costs, especially when bDMARDs are tapered. However, tapering treatment may lead to more transient or persistent disease flares, which have a direct impact on patients' lives and societal costs. <h3>Objectives</h3> The aim of this study is to evaluate the difference in cost-effectiveness of tapering csDMARD or anti-TNF therapy during one year of follow-up. <h3>Methods</h3> The TARA trial is a multicenter single-blinded randomised controlled trial. Included were RA patients that used a combination of csDMARDs and anti-TNF and who were at least for 3 months in sustained remission, defined as a DAS≤2.4 and a swollen joint count (SJC) ≤1. Patients were randomised into gradual tapering csDMARDs followed by the TNF blocker or vice versa. Medication was tapered in three steps over the course of 6 months. Gradual tapering was done by cutting the dosage into half, a quarter and thereafter it was stopped. Data on QALYs (measured with the Dutch EuroQol [EQ5D]), direct, and indirect costs were used to calculate the Incremental Cost Effectiveness Ratio (ICER). Direct costs comprises costs for treatment and medical consumption, while indirect costs comprises costs due to loss of productivity (i.e. sick leave and unemployment). <h3>Results</h3> A total of 187 patients were randomly assigned to tapering csDMARDs (n=93) or tapering anti-TNF (n=94). Patients had an average symptom duration of 6.7 years and were predominantly female (66%) with an average age of 56.4 years (figure 1A). Average QALYs (SD), over 1 year, for tapering csDMARDs or anti-TNF were, respectively, 0.82 (0.1) and 0.83 (0.1) (figure 1B). One year after inclusion a none significant difference in cumulative flare ratio of 9% was observed (overall flare ratio 36%). Patients in the anti-TNF tapering group had lower costs per QALY (SD) (€11 390 (6809)) compared to patients in the csDMARD tapering group (€21 804 (8329)). The difference in costs per QALY were mainly determined by the medication costs (figure 1B). The Incremental Cost Effectiveness Ratio (ICER, 95% CI) between tapering csDMARDs and anti-TNF was €31 922 (-€920572, €984416) (figure 1C). Tapering anti-TNF was &gt;95% cost-effective across all willingness-to-pay thresholds compared to tapering csDMARDs (figure 1D). <h3>Conclusions</h3> Tapering anti-TNF is more cost-effective compared to tapering csDMARDs. Therefore, in RA patients who are in sustained remission we advise to taper anti-TNF first, but before tapering therapy rheumatologist should take the risk of a disease flare and patient's wishes into account. <h3>Disclosure of Interest</h3> None declared