A budget impact analysis for making treatment decisions based on anti-cyclic citrullinated peptide (anti-CCP) testing in rheumatoid arthritis

Figures & data

Figure 1. Derivation of target population. ^aAssuming 0.5% RA prevalence¹⁹. ^bAssuming 65.5% of RA patients have moderate to severe disease activity²⁰. ^cAssuming 88.4% of patients use DMARD therapy²¹, of whom 39% use csDMARD and 61% use non-csDMARD²². 88.4% × 61% = 53.9%; 88.4% × 39% × 36.9% csDMARD non-responder²² = 12.7%. Abbreviations. csDMARD, conventional synthetic disease-modifying antirheumatic drug; DMARD, disease-modifying antirheumatic drug; JAKi, Janus kinase inhibitor; RA, rheumatoid arthritis.

Table 1. Treatment options and market share scenarios.

Drug class	Drug name	Scenario 1^25 (%)	Scenario 2 (%)
T-cell activation	Abatacept IV	7.90	9.23
	Abatacept SC	3.96	4.63
CD-20	Rituximab IV	6.51	6.36
TNFi biologics	Adalimumab SC	25.45	24.87
	Certolizumab pegol SC	3.05	2.98
	Etanercept SC	21.18	20.70
	Golimumab SC	1.47	1.44
	Golimumab IV	4.33	4.23
	Infliximab IV	10.55	10.31
	Infliximab dyyb IV	1.22	1.19
JAKi	Tofacitinib PO	9.09	8.88
	Baricitinib PO	0.17	0.17
IL-6	Sarilumab SC	0.61	0.59
	Tocilizumab IV	2.02	1.97
	Tocilizumab SC	2.20	2.15
IL-1	Anakinra SC	0.31	0.30

Abbreviations. IV, intravenous; IL, interleukin; PO, oral; JAKi, Janus kinase inhibitor; SC, subcutaneous; TNFi, tumor necrosis factor inhibitors.

Table 2. Medication costs (2019 US Dollars).

Drug name	Dose^a	Dose frequency^a	Strength	Package size	WAC (2019 USD)^28	Total pharmacy cost (2019 USD)^b
Abatacept IV	750 mg	Following initial dose, give at 2 and 4 weeks, then every 4 weeks.	250 mg	each	1,109.03	44,522.06
Abatacept SC	125 mg/1 mL	Once weekly	125 mg/1 mL	Four syringes	4,378.89	56,925.57
Rituximab IV	2 × 1,000 mg	Two 1,000 mg infusions every 24 weeks	10 mg/1 mL	10 mL	939.52	37,580.80
Adalimumab SC	40 mg	Every 2 weeks	40 mg/0.8 mL	Two syringes	5,174.09	67,263.17
Certolizumab pegol SC	400 mg for initial 3 doses, followed by 200 mg thereafter	Every 2 weeks	200 mg/1 mL	each	4,327.43	114,990.73
Etanercept SC	50 mg	Once weekly	50 mg/1 mL	Each	1,293.52	67,263.04
Golimumab SC	50 mg	Once monthly	50 mg/0.5 mL	Each	4,809.02	57,708.24
Golimumab IV	2 mg/kg	Taken at 0 and 4 weeks, then every 8 weeks thereafter	50 mg/4 mL	Each	1,818.51	52,306.46
Infliximab IV	3 mg/kg	Taken at 0, 2, and 6 weeks, then every 8 weeks thereafter	100 mg	Each	1,167.82	25,192.82
Infliximab dyyb IV	3 mg/kg	Taken at 0, 2, and 6 weeks, then every 8 weeks thereafter	100 mg	Each	946.28	20,413.65
Tofacitinib PO	5 mg	Twice daily	5 mg	60s each	4,480.63	54,514.33
Baricitinib PO	2 mg	Once daily	2 mg	30s each	2,136.90	25,998.95
Sarilumab SC	150 or 200 mg	Every 2 weeks	150–200 mg/1.14 ml	2 syringes	3,323.27	43,202.51
Tocilizumab IV	4–8 mg/kg	Every 4 weeks	20 mg/1 ml	4 mL	436.81	28,392.65
Tocilizumab SC	162 mg	Every 2 weeks	162 mg/0.9 ml	Each	984.72	25,602.72
Anakinra SC	100 mg	Once daily	100 mg/0.67 ml	Seven syringes	1,029.47	53,532.44

Abbreviations. IV, intravenous; PO, oral; SC, subcutaneous; USD, US dollar; WAC, wholesale acquisition cost.

^a Dose and dose frequency information from each product’s package insert.

^b The cost presented is before applying any rebates.

Table 3. Base case results: 30% rebate for adalimumab and etanercept, overall patients (2019 USD).

Outcome	Market share scenario 1	Market Share Scenario 2	Difference
Total budget impact	$102,040,450.00	$102,221,601.00	$181,151.00
Testing cost	$186,154.61	$206,838.45	$20,683.85
Pharmacy + administration cost	$101,854,295.04	$102,014,762.45	$160,467.41
Per member per year (PMPY)	$102.04	$102.22	$0.18
Per member per month (PMPM)	$8.50	$8.52	$0.015
Per patient per year (PPPY)	$46,783.00	$46,866.00	$83.00
Per patient per month (PPPM)	$3,899.00	$3,905.00	$7.00

Abbreviation. USD, United States dollar.

Table 4. Scenario analyses results (2019 USD).

Outcome	Market share scenario 1	Market share scenario 2	Difference
Scenario analysis: biologic or JAKi-naïve patients only
Total budget impact	$20,330,287.00	$20,379,109.00	$48,822.00
Testing cost	$35,525.90	$39,473.22	$3,947.32
Pharmacy + administration cost	$20,294,761.58	$20,339,636.26	$44,874.68
Per member per year (PMPY)	$20.33	$20.38	$0.05
Per member per month (PMPM)	$1.69	$1.70	$0.004
Per patient per year (PPPY)	$48,841.00	$48,959	$117.00
Per patient per month (PPPM)	$4,070.00	$4,080	$10.00
Scenario analysis: biologic or JAKi-experienced patients only
Total budget impact	$81,579,303.00	$81,714,843.00	$135,540.00
Testing cost	$150,628.71	$167,365.23	$16,736.52
Pharmacy + administration cost	$81,428,674.64	$81,547,477.80	$118,803.16
Per member per year (PMPY)	$81.58	$81.71	$0.14
Per member per month (PMPM)	$6.80	$6.81	$0.011
Per patient per year (PPPY)	$46,223.00	$46,300.00	$77.00
Per patient per month (PPPM)	$3,852.00	$3,858.00	$6.00
Scenario analysis: 30% discount for all TNF inhibitors; overall patients
Total budget impact	$95,811,264.00	$96,133,768.00	$322,504.00
Testing cost	$186,154.61	$206,838.45	$20,683.85
Pharmacy + administration cost	$95,625,109.12	$95,926,929.42	$301,820.30
Per member per year (PMPY)	$95.81	$96.13	$0.32
Per member per month (PMPM)	$7.98	$8.01	$0.027
Per patient per year (PPPY)	$43,927.00	$44,075.00	$148.00
Per patient per month (PPPM)	$3,661.00	$3,673.00	$12.00
Scenario analysis: 30% discount for all TNF and JAKi; overall patients
Total budget impact	$92,539,389.00	$92,936,139.00	$396,750.00
Testing cost	$186,154.61	$206,838.45	$20,683.85
Pharmacy + administration cost	$92,353,234.87	$92,729,300.65	$376,065.78
Per member per year (PMPY)	$92.54	$92.94	$0.40
Per member per month (PMPM)	$7.71	$7.74	$0.033
Per patient per year (PPPY)	$42,427.00	$42,609.00	$182.00
Per patient per month (PPPM)	$3,536.00	$3,551.00	$15.00

Abbreviations. JAKi, Janus kinase inhibitor; TNF, tumor necrosis factor; USD, United States dollar.

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