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Cost Effectiveness of Rituximab Therapy for Rheumatoid Arthritis: A Systematic Review and Meta-Analysis of Cost-Utility Studies

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Abstract

Background and Objectives

Depletion of B cells is shown to be clinically effective for rheumatoid arthritis (RA) treatment. Although B-cell depletion therapy with rituximab is indicated for RA patients who have failed to other disease-modifying anti-rheumatic drugs (DMARDs), primary cost-effectiveness evidence is inconsistent. We aimed to provide synthesised cost-effectiveness evidence of rituximab in the treatment of RA compared to other DMARDs, since the published cost-effectiveness evidence is mixed.

Methods

We identified economic evaluation studies reporting cost-utility of rituximab compared to other DMARDs by searching PubMed, Embase, Scopus, and Tufts Cost-Effective Analysis registry. Using random-effects meta-analysis, we pooled incremental net benefit (INB) in (purchasing power parity) adjusted US$ with 95% confidence intervals. We used the modified economic evaluations bias checklist and Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) instrument for quality appraisal. The study protocol was pre-registered with PROSPERO, CRD 42021222541.

Results

Of the selected 18 studies, the majority were from high-income countries (n = 14) followed by upper middle-income countries (n = 3) and lower middle-income countries (n = 1), with minimal risk of bias. Rituximab is significantly cost effective with a pooled INB (95% CI) of $8767 (720 to 16,814). On subgroup analysis, rituximab is significantly cost effective from a health system perspective [$12,832 (3392 to 22,272)], for studies using 3.5% discount rate [$15,468 (5973 to 24,963)] and a for a time horizon of less than 5 years [$8496 (1547 to 15,445)]. In a separate analysis, rituximab as third-line therapy (for conventional synthetic DMARDs followed by any other biologic DMARD failed patients) was not cost effective compared to DMARDs [$5314 (−2278 to 12,905)]. Further, the GRADE assessment indicated very-low confidence in the pooled results.

Conclusion

Rituximab is cost effective compared to other DMARDs but not if used as third-line therapy after failure of biologics. There is a need to generate context-specific evidence for the lower income settings.

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  1. Health Technology Assessment Resource Centre, Indian Council of medical Research–National Institute of Epidemiology, R-127, Tamil Nadu Housing Board, Phase I and II, Ayapakkam, Chennai, 600077, India

    S Sajith Kumar, Bhavani Shankara Bagepally & Akhil Sasidharan

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  1. S Sajith Kumar
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Correspondence to Bhavani Shankara Bagepally.

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No specific funding was received for this work. However, the Department of Health Research Government of India funds the Health Technology Assessment resource centre, ICMR-NIE. Funders had no role in the conceptualisation, conduction, and manuscript preparation.

Authors Contribution

SK: data curation, original draft, review & editing. BSB: conceptualisation, data curation, formal analysis, review & editing. AS: Original draft, review & editing.

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The authors (SK, AK, BSB) have no conflicts of interest to declare.

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Kumar, S.S., Bagepally, B.S. & Sasidharan, A. Cost Effectiveness of Rituximab Therapy for Rheumatoid Arthritis: A Systematic Review and Meta-Analysis of Cost-Utility Studies. Clin Drug Investig 43, 97–108 (2023). https://doi.org/10.1007/s40261-022-01238-3

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