朗讀皮下注射TNF-抑制劑治療強直性脊柱炎（AS）依從性的價值第皮下注射TNF-抑制劑治療強直性脊柱炎（AS）依從性的價值

皮下注射TNF-α抑制劑治療
強直性脊柱炎（AS）依從性的價值
背 景
僅從藥物獲取成本來看，皮下注射腫瘤壞死因子抑制劑（ SC-TNFi ）高治療依從性比低依從性的成本要高。 但這種說法忽視了前者對抵消不良健康護理成本、增加生產力和提高患者生活質量的積極影響。 
目 標
實驗透過比較SC-TNFi高低依從性的兩種療法，評估兩者對強直性關節炎（AS）的成本效益，從支付方和社會角度研究堅持SC-TNFi的價值所在。 
方 法
研究根據英國國家衛生與臨床技術最佳化研究所（NICE）構建的有關AS的York模型，設計出Markov 佇列研究模型。 在佇列模型中，對用藥12周BASDAI≥50的患者進行維持治療，對BASDAI ＜50的患者轉做常規治療。 兩組患者均面臨死亡風險。 治療反應期結束終止治療後，患者會出現病情反彈，即BASDAI和BASFI反彈回治療時的水平。 BASDAI和BASFI結果顯示，治療反應期結束後終止治療的患者病情加重，回到治療時的水平。 研究中的資料來自York模型，成本已根據2016/17價格進行了調整。 社會成本還包括生產率下降（包括曠工、假性出勤以及提前退休）帶來的間接成本。 研究分析了SC-TNFi兩種治療方案，兩組的中斷治療率分別為10%和20%。 除治療終止率外，兩組患者的其他治療要素均相同。 
結 果
儘管治療依從性高的SC-TNFi增加了治療成本，但其節約了一些與疾病相關的其他開支和社會成本，從而抵消了SC-TNFi增加的治療成本，實則節約了成本。 此外，以質量調整生命年（QALY）為標準，慢性患者健康狀況的改善是顯而易見的。 中斷治療率為10%和20%的SC-TNFi療法與常規療法的成本分別為£18,323 和 £20,063（見表一）。 因此，從社會學角度出發，依從性高的（患者付錢意願為£20,000）SC-TNFi療法，較之依從性低的（ICER= £16,112）療法更合算。 
結 論
依從性似乎是AS患者採用SC-TNFi治療是否合算的主要因素，從社會角度出發更是如此。 因此，提高SC-TNFi治療依從性可能更合算。 
原 文
The value of persistence in treatment with subcutaneous tnf-alpha inhibitors for ankylosing spondylitis
Background
Subcutaneous Tumor Necrosis Factor-alpha inhibitors (SC-TNFi) with higher persistence are often perceived as being more costly compared with SC-TNFis with lower persistence based merely on the resulting higher drug acquisition cost. Thus, failing to consider possible health care cost offsets, productivity gains and increased quality of life.
Objectives
The objective of this study was to assess the value of higher treatment persistence by evaluating cost-effectiveness of SC-TNFis for Ankylosing Spondylitis (AS), with higher persistence compared with lower persistence from a payer and societal perspective.
Methods
A Markov cohort model, following the framework of the NICE commissioned York model in AS1, was developed. In the model, patients achieving BASDAI50 response at 12 weeks transition to treatment maintenance and non-responders to conventional care. In each cycle, patients are at risk of death. Patients discontinuing treatment after the treatment response period rebounds in BASDAI and BASFI by what was gained at response. Inputs were sourced from the York model where available and costs were updated to 2016/17 prices. The societal perspective included indirect costs from productivity losses (i.e. absenteeism, presenteeism, and early retirement)2. Two treatment strategies are investigated; SC-TNFis with constant annual withdrawal rates of 10% and 20%. Apart from discontinuation rates, treatment inputs are the same for the two strategies.
Results
Better persistence increases the treatment cost, but this is partly offset by savings in disease related costs and from a societal perspective it is cost-saving. In addition, the improvement in the health of persistent patients is noticeable as a gain in quality adjusted life years (QALYs). The ICERs of the 10 % and 20% withdrawal rate treatment strategies versus conventional care (CC) are £18,323 and £20,063, respectively (table 1). Given a WTP of £20.000 the strategy with better persistence compared to the strategy with worse persistence is clearly cost-effective (ICER= £16,112) and dominates when a societal perspective is taken.
Conclusions
Persistence appears to be a driver of cost-effectiveness of SC-TNFi treatment in patients with AS, especially when a societal perspective is taken. Therefore, prescribing the SC-TNFi with the best persistence may be a cost-effective strategy.
文章出處：
Ivergård M, Dalén J, Svedbom A, et al. Annals of the Rheumatic Diseases 2018; 77:840-841. https://ard.bmj.com/content/77/Suppl_2/840.2.info

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