From the Guidelines
The cost of Disease-Modifying Antirheumatic Drugs (DMARDs) varies significantly, with traditional DMARDs like methotrexate being more affordable, typically costing $30-200 per month, while biologic DMARDs like etanercept and adalimumab are substantially more expensive, ranging from $1,000-5,000 monthly. When considering the treatment regimen of DMARDs, it's essential to prioritize the most recent and highest quality study, which in this case is the 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1. According to this guideline, methotrexate is strongly recommended over hydroxychloroquine or sulfasalazine for DMARD-naive patients with moderate-to-high disease activity, due to its disease-modifying properties and lower cost. The treatment regimen for traditional DMARDs includes:
- Methotrexate: usually started at 7.5-10mg once weekly, gradually increasing to 15-25mg weekly as needed, with folic acid supplementation to reduce side effects
- Hydroxychloroquine: 200-400mg daily
- Sulfasalazine: 2-3g daily in divided doses
- Leflunomide: loading dose of 100mg daily for 3 days, then 20mg daily For biologic DMARDs, the treatment regimen includes:
- Etanercept (Enbrel): 50mg weekly subcutaneous injections
- Adalimumab (Humira): 40mg subcutaneous injections every other week It's also important to consider the cost savings of tapering biologic DMARDs, as reported in a 2021 scoping review 1, which found that dose tapering can result in significant cost savings, ranging from 13% to 19.8% per year. Regular monitoring through blood tests is essential for all DMARDs to detect potential toxicities, with specific monitoring requirements varying by medication. Insurance coverage and patient assistance programs can also significantly impact out-of-pocket costs, making it essential to consider these factors when selecting a treatment regimen. Overall, the choice of DMARD should be based on a shared decision between the patient and the rheumatologist, taking into account the patient's individual needs, disease activity, and potential side effects, as recommended by the 2013 EULAR guidelines for the management of rheumatoid arthritis 1.
From the Research
Cost of DMARDs
- The cost of traditional DMARDs is up to $3000 per year, whereas the yearly drug costs for biologic DMARDs range between $16,000 and $20,000 2.
- The European League Against Rheumatism (EULAR) recommendations show that traditional DMARDs are cost-effective at the time of disease onset, as they are less expensive than biologic DMARDs 3.
- A systematic review and economic evaluation found that the incremental cost-effectiveness ratios (ICERs) for biologic DMARDs were £34,300 per quality-adjusted life-year (QALY) for adalimumab, £38,800 for etanercept, £36,200 for infliximab, £21,200 for rituximab, and £38,600 for abatacept, compared to DMARDs 4.
Treatment Regimen of DMARDs
- Traditional DMARDs, such as methotrexate, sulfasalazine, and leflunomide, are commonly used as the first line of treatment for rheumatoid arthritis 3, 2.
- Biologic DMARDs, such as etanercept, adalimumab, and infliximab, are used in combination with traditional DMARDs or as a second-line treatment for patients who have failed to respond to traditional DMARDs 5, 4.
- The treatment regimen for DMARDs typically involves a combination of medications, with the goal of achieving optimal disease control and minimizing side effects 6.
Effectiveness of DMARDs
- Traditional DMARDs have been shown to be effective in improving disease activity and function, and in reducing joint damage in patients with rheumatoid arthritis 3, 2.
- Biologic DMARDs have been shown to be more effective than traditional DMARDs in reducing disease activity and improving function, but are also associated with a higher risk of side effects 5, 4.
- The effectiveness of DMARDs can vary depending on the individual patient and the specific medication used, and treatment regimens may need to be adjusted over time to achieve optimal disease control 6.