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Biological Therapies for the Treatment of Severe Psoriasis in Patients with Previous Exposure to Biological Therapy: A Cost-Effectiveness Analysis

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Abstract

Background

Biologic therapies have revolutionised the care of patients with psoriasis, although they come at significant extra cost. Guidance on their use in the UK National Health Service (NHS) has so far focused on patients who are “biologic naive”, yet a minority of patients have poor response and require further treatment.

Objectives

To assess the potential cost effectiveness of sequential biologic therapies in patients with psoriasis who have been exposed to previous biologic therapy.

Methods

A two-part model with a 10-year time horizon was built to model an initial 13.5-week “trial” phase and a longer-term “treatment” period with annual Markov cycles. Psoriasis Area and Severity Index (PASI) response rates from subgroup analyses of three randomised placebo-controlled trials evaluating biologic agents were considered. A meta-analysis of these data provided probabilities of achieving PASI response (50/75/90) in the short term, and published evidence and assumptions were used to predict outcomes over the longer term. Benefits were measured in quality-adjusted life years (QALYs), and costs (2013–14) to the UK NHS included drugs, administration, monitoring, and hospitalisation. Costs and benefits were discounted 3.5 % per annum. Cost effectiveness of sequential biologic therapy was measured using an incremental cost-effectiveness ratio (ICER) compared to best supportive care (BSC). Extensive sensitivity analyses were performed to assess the impact of alternative assumptions on the results.

Results

Results indicate that over 10 years, switching to a second biologic following intolerance to or failure of a first is likely to generate more QALYs than BSC, but at a higher cost. Base case results suggest the ICER of the second biologic compared to BSC is £17,681 per QALY; however, sensitivity analyses indicate that changes in the efficacy of BSC, drug costs, dropout rates, and rates of hospitalisation have a significant impact, causing the ICER to range from less than £10,000 to over £50,000 per QALY.

Conclusions

Further biologic therapy for patients with psoriasis who have previously been treated with biologic therapy may be cost effective, although there is considerable uncertainty in the results. Future studies should be designed to evaluate the clinical efficacy of biologic therapies in this subgroup with particular attention given to short-term and longer-term responses.

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References

  1. National Institute for Health and Clinical Excellence. Etanercept and efalizumab for the treatment of adults with psoriasis. NICE technology appraisal 103. London: National Institute for Health and Clinical Excellence; 2006.

  2. National Institute for Health and Clinical Excellence. Infliximab for the treatment of adults with psoriasis. NICE technology appraisal 134. GIN, editor. London: National Institute for Health and Clinical Excellence. International Guidelines Library; 2008.

  3. National Institute for Health and Clinical Excellence. Adalimumab for the treatment of adults with psoriasis. NICE technology appraisal 146. London: National Institute for Health and Clinical Excellence. International Guidelines Library; 2008.

  4. National Institute for Health and Clinical Excellence. Ustekinumab for the treatment of adults with moderate to severe psoriasis. NICE technology appraisal 180. GIN, editor. London: National Institute for Health and Clinical Excellence. International Guidelines Library; 2009.

  5. Mauskopf J, Samuel M, McBride D, Mallya UG, Feldman SR. Treatment sequencing after failure of the first biologic in cost-effectiveness models of psoriasis: a systematic review of published models and clinical practice guidelines. Pharmacoeconomics. 2014.

  6. National Institute for Health and Clinical Excellence. Psoriasis: the assessment and management of psoriasis: NICE clinical guideline 153. London: National Institute for Health and Clinical Excellence; 2012.

  7. National Institute for Health and Clinical Excellence. Guide to the methods of technology appraisal. London: National Institute for Health and Clinical Excellence; 2013.

  8. Woolacott N, Hawkins N, Mason A, Kainth A, Khadjesari Z, Vergel YB, et al. Etanercept and efalizumab for the treatment of psoriasis: a systematic review. Health Technol Assess. 2006;10(46):1–252.

    Article  CAS  PubMed  Google Scholar 

  9. Leonardi CL, Kimball AB, Papp KA, Yeilding N, Guzzo C, Wang Y, et al. Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 1). Lancet. 2008;371(9625):1665–74.

    Article  CAS  PubMed  Google Scholar 

  10. Menter A, Feldman SR, Weinstein GD, Papp K, Evans R, Guzzo C, et al. A randomized comparison of continuous vs. intermittent infliximab maintenance regimens over 1 year in the treatment of moderate-to-severe plaque psoriasis. J Am Acad Dermatol. 2007;56(1):31.

    Article  PubMed  Google Scholar 

  11. Papp KA, Langley RG, Lebwohl M, Krueger GG, Szapary P, Yeilding N, et al. Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 52-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 2). Lancet. 2008;371(9625):1675–84.

    Article  CAS  PubMed  Google Scholar 

  12. Centre National Clinical Guideline. Psoriasis: the management of psoriasis. London: National Clinical Guideline Centre; 2012.

    Google Scholar 

  13. National Institute for Health and Clinical Excellence. The guidelines manual. London: National Institute for Health and Clinical Excellence; 2009.

  14. Janssen Cilag. Clinical efficacy data from phase III study PHOENIX 1, broken down into patients’ medication history with biologic therapies [unpublished data]. 2011.

  15. Janssen Cilag. Clinical efficacy data from phase III study PHOENIX 2 broken down into patients’ medication history with biologic therapies [unpublished data]. 2011.

  16. Janssen Cilag. Clinical efficacy data from phase III study ACCEPT broken down into patients’ medication history with biologic therapies [unpublished data]. 2011.

  17. Reich K, Burden AD, Eaton JN, Hawkins NS. Efficacy of biologics in the treatment of moderate to severe psoriasis: a network meta-analysis of randomized controlled trials. Br J Dermatol. 2012;166(1):179–88.

    Article  CAS  PubMed  Google Scholar 

  18. Dias S, Sutton AJ, Ades AE, Welton NJ. Evidence synthesis for decision making 2: a generalized linear modeling framework for pairwise and network meta-analysis of randomized controlled trials. Med Decis Making. 2013;33(5):607–17.

    Article  PubMed Central  PubMed  Google Scholar 

  19. Gniadecki R, Bang B, Bryld LE, Iversen L, Lasthein S, Skov L. Comparison of long-term drug survival and safety of biologic agents in patients with psoriasis vulgaris. Br J Dermatol. 2014.

  20. Menting SP, Sitaram AS, Bonnerjee-van der Stok HM, de Rie MA, Hooft L, Spuls PI. Drug survival is not significantly different between biologics in patients with psoriasis vulgaris: a single-centre database analysis. Br J Dermatol. 2014.

  21. van den Reek JM, Tummers M, Zweegers J, Seyger MM, Van Lumig PP, Driessen RJ, et al. Predictors of adalimumab drug survival in psoriasis differ by reason for discontinuation: long-term results from the Bio-CAPTURE registry. J Eur Acad Dermatol Venereol. 2014.

  22. van den Reek JM, Van Lumig PP, Driessen RJ, van de Kerkhof PC, Seyger MM, Kievit W, et al. Determinants of drug survival for etanercept in a long-term daily practice cohort of patients with psoriasis. Br J Dermatol. 2014;170(2):415–24.

    Article  PubMed  Google Scholar 

  23. Pathirana D, Ormerod AD, Saiag P, Smith C, Spuls PI, Nast A, et al. European S3-guidelines on the systemic treatment of psoriasis vulgaris. J Eur Acad Dermatol Venereol. 2009;23(Suppl 2):1–70.

    Article  PubMed  Google Scholar 

  24. Paul C, Gallini A, Maza A, Montaudie H, Sbidian E, Aractingi S, et al. Evidence-based recommendations on conventional systemic treatments in psoriasis: systematic review and expert opinion of a panel of dermatologists. J Eur Acad Dermatol Venereol. 2011;25(Suppl 2):2–11.

    Article  PubMed  Google Scholar 

  25. Currie CJ, McEwan P, Peters JR, Patel TC, Dixon S. The routine collation of health outcomes data from hospital treated subjects in the Health Outcomes Data Repository (HODaR): descriptive analysis from the first 20,000 subjects. Value Health. 2005;8(5):581–90.

    Article  PubMed  Google Scholar 

  26. National Institute for Health and Clinical Excellence. Ustekinumab (Stelara) for the treatment of moderate to severe plaque psoriasis in England and Wales—Single Technology Appraisal Manufacturer Submission. Available http://www.nice.org.uk/guidance/ta180/documents/psoriasis-ustekinumab-manufacturer-submission-janssencilag2. 2009.

  27. Norlin JM, Steen CK, Persson U, Schmitt-Egenolf M. Analysis of three outcome measures in moderate to severe psoriasis: a registry-based study of 2450 patients. Br J Dermatol. 2012;166(4):797–802.

    Article  CAS  PubMed  Google Scholar 

  28. Joint Formulary Committee. British national formulary (BNF). 68th ed. London: British Medical Association and The Royal Pharmaceutical Society of Great Britain; 2014.

    Google Scholar 

  29. Department of Health. NHS reference costs 2009–2010. (2011 [cited 2011 Aug. 1]) Available http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123459.

  30. Curtis L. Unit costs of social health care. Canterbury: Personal Social Services Reseach Unit, University of Kent; 2013.

    Google Scholar 

  31. Fonia A, Jackson K, Lereun C, Grant DM, Barker JNWN, Smith CH. A retrospective cohort study of the impact of biologic therapy initiation on medical resource use and costs in patients with moderate to severe psoriasis. Br J Dermatol. 2010;163(4):807–16.

    Article  CAS  PubMed  Google Scholar 

  32. Driessen RJ, Bisschops LA, Adang EM, Evers AW, van de Kerkhof PC, de Jong EM. The economic impact of high-need psoriasis in daily clinical practice before and after the introduction of biologics. Br J Dermatol. 2010;162(6):1324–9.

    Article  CAS  PubMed  Google Scholar 

  33. Woods AL, Rutter KJ, Gardner LS, Lewis VJ, Saxena S, George SA, et al. Inpatient management of psoriasis: a multicentre service review to establish national admission standards. Br J Dermatol. 2008;158(2):266–72.

    Article  CAS  PubMed  Google Scholar 

  34. Sizto S, Bansback N, Feldman SR, Willian MK, Anis AH. Economic evaluation of systemic therapies for moderate to severe psoriasis. Br J Dermatol. 2009;160(6):1264–72.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

This work was undertaken by the National Clinical Guideline Centre, which received funding from the National Institute for Health and Care Excellence. The views expressed in this publication are those of the authors and not necessarily those of the Institute.

All authors were members of the National Institute for Health and Care Excellence Psoriasis Guideline Development Group (CHS chaired the group, KJ and RM were clinical members, LS and DW were the health economists, and ES was the research fellow). LS was responsible for the design and development model and evidence synthesis and led the overall economic analysis. DW performed model validation and assisted with running sensitivity analysis. KJ, RM, and CHS provided expert clinical opinion on the model structure, advised on missing data, and contributed to the definition of best supportive care. ES performed the systematic review of the clinical literature and prepared data for meta-analysis. LS is the guarantor for the overall content.

We gratefully acknowledge the advice and input of the following members of the Psoriasis Guideline Development Group and experts who advised the group regarding this evaluation: David Chandler, Paul Hepple, Jillian Peters, Natasha Smeaton, Claire Strudwicke, Roderick Tucker, Richard Warren, Jill Cobb, Nancy Pursey, Amelia Ch’ng, and Jill Parnham.

Funding sources

National Institute for Health and Care Excellence.

COI disclosures

All authors were members of the National Institute for Health and Care Excellence Psoriasis Guideline Development Group (CHS chaired the group, KJ and RM were clinical members, LS and DW were the health economists, and ES was the research fellow). After completing the guideline analysis but before its publication, LS joined Symmetron Limited. CS has received funding from Novartis and Pfizer for departmental research. KJ has received an unrestricted grant from Abbvie to support the development of a clinical psychology service, and has been paid for the development and delivery of educational lectures for Abbvie, Janssen-Cilag, and Pfizer (2011–14). RM has received lecture fees from Janssen-Cilag (2013–14).

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Authors and Affiliations

  1. National Clinical Guideline Centre, Royal College of Physicians of London, 11 St Andrews Place, London, NW1 4LE, UK

    David Wonderling & Eleanor J. Samarasekera

  2. Division of Medicine and Molecular Genetics, St John’s Institute of Dermatology, Guys Hospital, London, SE1 9RT, UK

    Karina Jackson & Catherine H. Smith

  3. Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK

    Ruth Murphy

  4. Symmetron Limited, Kinetic Centre, Theobald Street, Borehamwood, Hertfordshire, WD6 4PJ, UK

    Laura M. Sawyer

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  1. Laura M. Sawyer
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Correspondence to Laura M. Sawyer.

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Sawyer, L.M., Wonderling, D., Jackson, K. et al. Biological Therapies for the Treatment of Severe Psoriasis in Patients with Previous Exposure to Biological Therapy: A Cost-Effectiveness Analysis. PharmacoEconomics 33, 163–177 (2015). https://doi.org/10.1007/s40273-014-0226-y

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