Treatment strategies aiming at remission in early rheumatoid arthritis patients: starting with methotrexate monotherapy is cost-effective

Rheumatology (Oxford). 2011 Jul;50(7):1320-30. doi: 10.1093/rheumatology/ker084. Epub 2011 Mar 2.


Objective: To perform a modelling study on the cost-effectiveness of three outcome-directed strategies in early RA patients: Strategy 1: starting MTX monotherapy, followed by the addition of LEF, followed by MTX with addition of anti-TNF; Strategy 2: start with MTX and LEF combination followed by MTX with anti-TNF; and Strategy 3: immediate start with MTX and anti-TNF.

Methods: A validated Markov model was used to evaluate the cost-effectiveness of the three strategies. Effectiveness of the strategies was determined using daily practice data from two cohorts and used as input parameter in the model. Patients treated according to the strategies were matched for baseline 28-joint DAS (DAS-28). Using Monte Carlo simulation, expected costs, quality-adjusted life-years (QALYs) and incremental cost per QALY gained for a 5-year time horizon were calculated following both a health-care and a societal perspective.

Results: The percentage of patients in remission and number of QALYs were comparable between the three strategies. Starting with a combination (MTX plus LEF or anti-TNF) was more costly than starting with MTX alone. This resulted in an unfavourable incremental cost-effectiveness ratio for starting on anti-TNF vs initially MTX: health-care perspective of €138,028 and from a societal perspective of €136,150 per QALY gained over 5 years.

Conclusion: In this modelling study, starting with MTX or anti-TNF has comparable effectiveness. However, initial anti-TNF was far more expensive than starting with MTX monotherapy. Therefore, based on this study, a treatment strategy starting with MTX monotherapy is favoured over a strategy with MTX and anti-TNF right away in early RA patients.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Antirheumatic Agents / economics
  • Antirheumatic Agents / therapeutic use
  • Arthritis, Rheumatoid / diagnosis
  • Arthritis, Rheumatoid / drug therapy*
  • Arthritis, Rheumatoid / economics*
  • Cohort Studies
  • Cost of Illness
  • Cost-Benefit Analysis
  • Drug Costs*
  • Drug Therapy, Combination
  • Early Diagnosis
  • Female
  • Follow-Up Studies
  • Humans
  • Isoxazoles / economics*
  • Isoxazoles / therapeutic use
  • Leflunomide
  • Male
  • Markov Chains
  • Methotrexate / economics*
  • Methotrexate / therapeutic use
  • Middle Aged
  • Netherlands
  • Severity of Illness Index
  • Treatment Outcome
  • Tumor Necrosis Factor-alpha / antagonists & inhibitors
  • Tumor Necrosis Factor-alpha / economics


  • Antirheumatic Agents
  • Isoxazoles
  • Tumor Necrosis Factor-alpha
  • Leflunomide
  • Methotrexate