Biologic drugs for rheumatoid arthritis in the Medicare program: a cost-effectiveness analysis

Arthritis Rheum. 2008 Apr;58(4):939-46. doi: 10.1002/art.23374.


Objective: Since the introduction of the Medicare Prescription Drug Improvement and Modernization Act and its associated demonstration project, coverage of selected biologic drugs has been expanded for Medicare beneficiaries. For rheumatoid arthritis, coverage was extended to etanercept, adalimumab, and anakinra in addition to the previously covered infliximab. We undertook to develop a model to compare the costs and quality-adjusted life years (QALYs) generated by each of the 4 biologic agents.

Methods: Data were drawn from meta-analysis of randomized controlled trials and from a large longitudinal outcomes databank. Uncertainty was addressed using probabilistic and one-way sensitivity analyses. A lifetime horizon and Medicare viewpoint were adopted.

Results: In the base case analysis, anakinra was the least effective and least costly strategy. Etanercept, adalimumab, and infliximab were similar in terms of effectiveness, but infliximab was more costly. If decision makers are willing to pay a maximum of $50,000/QALY, the probability that infliximab is cost-effective is <1%. Findings were robust to a range of sensitivity analyses. Only if the dose of infliximab remains constant over time is this likely to be a cost-effective strategy.

Conclusion: Infliximab is unlikely to be cost-effective in the Medicare population compared with either etanercept or adalimumab. Anakinra is substantially less costly but is also less effective than the 3 tumor necrosis factor alpha inhibitors.

Publication types

  • Comparative Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adalimumab
  • Antibodies, Monoclonal / economics
  • Antibodies, Monoclonal / therapeutic use
  • Antibodies, Monoclonal, Humanized
  • Arthritis, Rheumatoid / drug therapy*
  • Arthritis, Rheumatoid / economics
  • Cost-Benefit Analysis / economics
  • Etanercept
  • Humans
  • Immunoglobulin G / economics
  • Immunoglobulin G / therapeutic use
  • Immunologic Factors / economics*
  • Immunologic Factors / therapeutic use
  • Infliximab
  • Interleukin 1 Receptor Antagonist Protein / economics
  • Interleukin 1 Receptor Antagonist Protein / therapeutic use
  • Medicare Part B / economics*
  • Meta-Analysis as Topic
  • Models, Economic*
  • Quality-Adjusted Life Years*
  • Randomized Controlled Trials as Topic
  • Receptors, Tumor Necrosis Factor / therapeutic use
  • Tumor Necrosis Factor-alpha / antagonists & inhibitors
  • United States


  • Antibodies, Monoclonal
  • Antibodies, Monoclonal, Humanized
  • Immunoglobulin G
  • Immunologic Factors
  • Interleukin 1 Receptor Antagonist Protein
  • Receptors, Tumor Necrosis Factor
  • Tumor Necrosis Factor-alpha
  • Infliximab
  • Adalimumab
  • Etanercept