ABSTRACT
OBJECTIVE: The aim of the current study was to evaluate the 2-year cost-utility ratio between tapering conventional synthetic disease-modifying antirheumatic drugs (csDMARD) first followed by the tumour necrosis factor (TNF)-inhibitor, or vice versa, in patients with rheumatoid arthritis (RA). METHODS: Two-year data of the Tapering strategies in Rheumatoid Arthritis trial were used. Patients with RA, who used both a csDMARD and a TNF-inhibitor and had a well-controlled disease (disease activity score ≤2.4 and swollen joint count≤1) for at least 3 months, were randomised into gradual tapering the csDMARD first followed by the TNF-inhibitor, or vice versa. Quality-adjusted life years (QALYs) were derived from the European Quality of life questionnaire with 5 dimensions. Healthcare and productivity costs were calculated with data from patient records and questionnaires. The incremental cost-effectiveness ratio and the incremental net monetary benefit were used to assess cost effectiveness between both tapering strategies. RESULTS: 94 patients started tapering their TNF-inhibitor first, while the other 95 tapered their csDMARD first. QALYs (SD) were, respectively, 1.64 (0.22) and 1.65 (0.22). Medication costs were significantly lower in the patients who tapered the TNF-inhibitor first, while indirect cost were higher due to more productivity loss (p=0.10). Therefore, total costs (SD) were 38 833 (39 616) for tapering csDMARDs first, and 39 442 (47 271) for tapering the TNF-inhibitor (p=0.88). For willingness-to-pay (WTP) levels <83 800 tapering, the csDMARD first has the highest probability of being cost effective, while for WTP levels >83 800 tapering the TNF-inhibitor first has the highest probability. CONCLUSION: Our economic evaluation shows that costs are similar for both tapering strategies. Regardless of the WTP, tapering either the TNF-inhibitor or the csDMARD first is equally cost effective. TRIAL REGISTRATION NUMBER: NTR2754.
Subject(s)
Antirheumatic Agents/administration & dosage , Antirheumatic Agents/economics , Arthritis, Rheumatoid/drug therapy , Cost-Benefit Analysis , Tumor Necrosis Factor Inhibitors/administration & dosage , Tumor Necrosis Factor Inhibitors/economics , Adult , Aged , Female , Humans , Male , Middle Aged , Quality-Adjusted Life Years , Single-Blind Method , Symptom Flare Up , Treatment OutcomeABSTRACT
Sulfasalazine (SSZ) can induce serological and clinical autoimmune reactions but the occurrence of SSZ-related Wegener's granulomatosis (WG) has not been reported before. We describe two patients with rheumatoid factor (RF)-positive rheumatoid arthritis (RA) who developed biopsy-proven WG with serious organ involvement during SSZ therapy. The pathogenetic mechanism that explains the relationship between SSZ and the occurrence of a de novo anti-neutrophil cytoplasmic antibody (ANCA)-related vasculitis or a flare is discussed. We propose that WG can be a rare complication of SSZ therapy and that this, like other autoimmune adverse events of this drug, is mediated by SSZ-induced apoptosis.
Subject(s)
Disease Progression , Granulomatosis with Polyangiitis/drug therapy , Granulomatosis with Polyangiitis/physiopathology , Sulfasalazine/adverse effects , Sulfasalazine/therapeutic use , Adult , Aged , Antirheumatic Agents/adverse effects , Antirheumatic Agents/therapeutic use , C-Reactive Protein/metabolism , Cyclophosphamide/therapeutic use , Glucocorticoids/therapeutic use , Humans , Methylprednisolone/therapeutic useABSTRACT
A 1-year complete remission could be achieved with high-dose systemic chemotherapy in a 33-year-old patient with relapsed germ cell tumor presenting with leptomeningeal carcinomatosis (LC). Although LC in general has a very poor prognosis for patients with chemosensitive malignancies, systemic chemotherapy should be considered.
