Abstract
Objectives Disease-modifying anti-rheumatic drugs (DMARDs) are the standard first-line therapy for psoriatic arthritis (PsA), effectively improving clinical symptoms and health-related quality of life. While conventional synthetic DMARDs (csDMARDs) are typically prescribed initially, targeted synthetic (tsDMARDs) and biologic DMARDs (bDMARDs) have demonstrated efficacy in improving joint and skin outcomes, achieving minimal disease activity (MDA), and preventing radiographic progression.[1] Emerging evidence suggests that delayed DMARD initiation is associated with worse functional outcomes, lower MDA achievement rates, and greater irreversible joint damage.[2] This cost-utility analysis evaluates the economic and health-related impacts of early vs delayed DMARD initiation for DMARD-naïve adult PsA patients, comparing direct medical costs and quality-adjusted life-years (QALYs).
Methods A Markov model simulated disease progression over 5 years using monthly cycles from a U.S. payer perspective. Transition probabilities, EQ-5D utilities, and healthcare resource utilization were derived from a targeted literature review. Patients began in a pre-treatment state and transitioned monthly among 4 health states following DMARD initiation: complete response (sustained MDA), partial response (non-sustained MDA), non-response (did not meet MDA), or death. Modeled therapies included methotrexate (csDMARD), tofacitinib or apremilast (tsDMARDs), and biologic DMARDs (bDMARDs). Early initiation was defined as ≤1 year after PsA diagnosis and delayed initiation occurred >1 year after diagnosis. The mean time from diagnosis to DMARD initiation was 0.2 years in the early group and 8.6 years in the delayed group. Cost differences between exposure groups were modeled using a regression equation linking Health Assessment Questionnaire Disability Index (HAQ-DI) scores to direct medical costs, where higher HAQ-DI scores were associated with higher costs.[3]
Results Early DMARD initiation resulted in a gain of 0.33 QALYs and a cost savings of USD$7,473.52 per patient relative to delayed initiation, producing a dominant incremental cost-effectiveness ratio of −USD$22,479.24/QALY (Figure 1). The model was most sensitive to changes in direct medical costs (range: −USD$206,875.18/QALY to USD$161,915.70/QALY) and MDA rates (range: −USD$437,673.70/QALY to −USD$14,947.59/QALY).
Conclusion This study demonstrates that early DMARD initiation in DMARD-naïve patients with PsA provides superior clinical and economic outcomes compared to delayed initiation, making it the dominant strategy. The substantial economic value of early initiation is largely driven by achieving early disease control, preventing irreversible joint damage, and improving long-term functional outcomes. These benefits translate into reduced healthcare costs and greater patient outcomes, reinforcing the importance of early therapeutic intervention and advocating for the reconsideration of reimbursement frameworks to allow timely access to effective treatment.
References [1.] Ciliento M. Int J Mol Sci 2023;24:5006. [2.] Mease P. ACR Open Rheumatol 2025;7:e70019. [3.] Ogdie A. J Manag Care Spec Pharm 2022;28:997-1007.
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