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The value of persistence in treatment with subcutaneous TNF-alpha inhibitors for ankylosing spondylitis



To estimate the impact of persistence on cost-effectiveness of subcutaneous tumor necrosis factor-α inhibitors (SC-TNFis) from healthcare and societal perspectives in a United Kingdom ankylosing spondylitis (AS) population using a recently published Markov cohort model.


A recently published cost-effectiveness model developed for a National Institute for health and Care Excellence appraisal was extended to fit the current study; in brief, it is a Markov cohort model where treatment responders continue from the trial period with maintenance SC-TNFi treatment, while non-responders transition to conventional care. Costs and effects were modeled for a hypothetical SC-TNFi with average efficacy and price. Model outcomes included quality-adjusted life-years (QALYs), total direct and indirect lifetime costs, and incremental cost-effectiveness ratios (ICERs). The cost-effectiveness of SC-TNFi persistence was estimated by decreasing the annual discontinuation probability in five percentage point increments from 25 to 5% per annum.


From a health care perspective, the ICERs for the modeled discontinuation rates compared to the baseline annual discontinuation rate (25%) ranged between GBP 17,277 and GBP 18,161. From a societal perspective, increased discontinuation rates resulted in decreased total costs and higher QALYs; hence, lower discontinuation rates dominated higher discontinuation rates from a societal perspective.


In conclusion, this study shows that, all else equal, higher SC-TNFi treatment persistence in AS is cost effective from a health care perspective and dominant from a societal perspective. Hence, all else equal, prescribing the SC-TNFi with the highest persistence may be considered a cost-effective strategy.

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Corresponding author

Correspondence to Sumesh Kachroo.

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Conflict of interest

The authors report no other conflicts of interest in this work.

Ethical approval

This study was supported by Merck & Co., Inc. S Kachroo, C Black, and R Borse are employees of Merck & Co., Kenilworth, NJ, USA, and hold stock and options. A Svedbom, J Dalén, M Ivergård, and K Luttropp were paid consultants to Merck through their employment at ICON Clinical Research. ICON Clinical Research has received funding from several pharmaceutical companies involved in the marketing of products for treatment of rheumatic disease.

Human and animal rights

This study was supported by Merck & Co., Inc. Given that the work relies on synthesis of publically available data, the research did not involve human participants and/or animals.

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Svedbom, A., Dalén, J., Ivergård, M. et al. The value of persistence in treatment with subcutaneous TNF-alpha inhibitors for ankylosing spondylitis. Eur J Health Econ 21, 45–54 (2020).

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  • Cost–benefit analysis
  • Medication persistence
  • Economic evaluation
  • Ankylosing spondylitis
  • Bechterew’s disease

JEL Classification

  • I120