To perform a cost effectiveness analysis of cyclosporine (CyA) in the treatment of rheumatoid arthritis (RA).
Five randomized controlled parallel group clinical trials were selected for metaanalysis. A fixed effects model was used to calculate the treatment effects among the studies. An incremental economic analysis was performed from both a societal perspective and the perspective of Ontario Ministry of Health (MOH). A placebo comparison and 2 head to head comparisons were performed. The total treatment cost was calculated for a typical patient based on a modified intent to treat approach modelled over a one year period.
CyA produced a 25% or greater improvement in tender joint account in 35% of the patients relative to 17% of patients receiving placebo. There was no significant difference in improvement between CyA and azathioprine (Aza) or D-penicillamine (D-Pen). From the perspective of the Ontario MOH, the annual incremental cost of achieving the same level of improvement between CyA and Aza was found to be $1,473, and between CyA and D-Pen, $1,618; the annual incremental cost effectiveness ratio per patient improved of adopting CyA over placebo was $11,547. From a societal perspective, the incremental cost of CyA was $2,886 and $3,731 between Aza and D-Pen, respectively. The annual incremental cost effectiveness ratio against placebo was $20,698.
Given budgetary constraints on provincial drug plans, guidelines identifying patients in whom the cost effectiveness of CyA may be expected to be most favorable need to be explored. When CyA is the last option available to alleviate RA, whether it is "good value for money" depends upon the importance placed on patient improvement by the patients and/or by society, and on the alternative uses of the same scarce resources.