The tumor necrosis factor-α-inhibitor drugs adalimumab, etanercept, and infliximab should be used to treat rheumatoid arthritis patients only after 6-month trials of methotrexate and one other disease-modifying antirheumatic drug, the clinical effectiveness agency for England and Wales had ruled.
The TNF-α inhibitors should be prescribed only to those patients who have active rheumatoid arthritis as measured by a disease activity score greater than 5.1—or patients with about 8–10 swollen and tender joints—confirmed at least twice, measured 1 month apart, according to the National Institute for Health and Clinical Effectiveness' final appraisal document.
TNF-α-inhibitor therapy should be done in combination with methotrexate, unless contraindicated, according to NICE. In those instances, patients should receive either adalimumab or etanercept as monotherapy.
Physicians should stop treatment with TNF-α inhibitors after 6 months if the patient does not show an adequate response, defined as an improvement in disease activity score of at least 1.2 points.
Infliximab costs between $14,612 and $17,047 a year, while etanercept and adalimumab both cost $17,982 a year, according to the NICE committee examining the effectiveness of the three drugs.
The committee considered TNF-α-inhibitor medications as first-line or second-line therapy after failure of one disease-modifying antirheumatic drug (DMARD). However, the committee concluded, based on cost and efficacy data, that neither was an appropriate use of National Health Service resources.
For first-line therapy, clinical specialists told the appraisal committee that a large number of patients initially respond well to DMARDs, and both the British Society of Rheumatology and European League Against Rheumatism recommend a trial of at least one DMARD.
As a second-line treatment, the appraisal committee did not believe TNF-α inhibitors had demonstrated cost-effectiveness.