Cost-Effectiveness Analysis of First-Line Treatment With Biologic Agents in Polyarticular Juvenile Idiopathic Arthritis.

OBJECTIVE: The optimal timing of biologic agent treatment in polyarticular juvenile idiopathic arthritis (JIA) is unknown. This study evaluated the costs and outcomes of first-line treatment with etanercept (ETN), an anti-tumor necrosis factor (anti-TNF) agent, compared with step-wise therapy in JIA. METHODS: We compared 2 strategies: methotrexate (MTX) plus ETN as first-line therapy (ETN-first) and MTX monotherapy followed by ETN (ETN-second), using a cohort state-transition model of newly diagnosed JIA patients. The model's time horizon was 5 years, and the perspective was that of the Canadian health care system. The base case patient was 11 years old, weighed 40 kg, and had 5 or more active joints. Direct costs were calculated and discounted at a rate of 3% per year. Outcomes were expressed as quality-adjusted life years (QALYs). Scenario analyses varied multiple parameters simultaneously to model more severely and more mildly affected patients. RESULTS: ETN-first, compared to ETN-second, yielded a discounted incremental cost of $16,893 (95% confidence interval [95% CI] 9,348-25,310), incremental QALY of 0.19 (95% CI 0.08-0.32), and an incremental cost-effectiveness ratio of $88,815 per QALY gained. The results were sensitive to the cost of ETN, the time horizon of the model, and estimates of the efficacy of the first-line therapies. The cost per QALY for treating patients with severe JIA was $33,960. CONCLUSION: First-line therapy of ETN and MTX is relatively expensive compared to MTX alone, but may be economically attractive for more severely affected patients. More research is needed regarding the efficacy of first-line anti-TNF agents.

Secondary injury mechanisms of spinal cord trauma: a novel therapeutic approach for the management of secondary pathophysiology with the sodium channel blocker riluzole.

Traumatic spinal cord injury is a consequence of a primary mechanical insult and a sequence of progressive secondary pathophysiological events that confound efforts to mitigate neurological deficits. Pharmacotherapy aimed at reducing the secondary injury is limited by a narrow therapeutic window. Thus, novel drug strategies must target early pathological mechanisms in order to realize the promise of efficacy for this form of neurotrauma. Research has shown that an accumulation of intracellular sodium as a result of trauma-induced perturbation of voltage-sensitive sodium channel activity is a key early mechanism in the secondary injury cascade. As such, voltage-sensitive sodium channels are an important therapeutic target for the treatment of spinal cord trauma. This review describes the evolution of acute spinal cord injury and provides a rationale for the clinical utility of sodium channel blockers, particularly riluzole, in the management of spinal cord trauma.

An in vitro model of neurotrauma in organotypic spinal cord cultures from adult mice.

Cellular degeneration after spinal cord injury (SCI) involves numerous pathways. It is essential to use appropriate experimental models in order to understand the complex processes, which evolve after the initial trauma. The purpose of this study was to develop and assess an in vitro model of neurotrauma using organotypic slice culture of adult mice spinal cord. This model will facilitate the investigation of primary and secondary mechanisms of cell death that occurs after SCI. We modified previously described methods for generating organotypic cultures of murine spinal cord. The viability of organotypic cultures was assessed by observing the outgrowth of neurites and by using a mitochondria dependent dye for live cells (tetrazolium dye; MTT). The morphological integrity of cultures was examined histologically by hematoxylin and eosin (H&E) staining for general morphology and with luxol fast blue (LFB) for myelin. Neuronal and glial (GFAP; CNPase) markers were used to identify neurons, astrocytes and oligodendroglia, respectively. Primary injury was achieved by using a weight drop (0.2 g) model of injury. Cell death after primary injury was attenuated by pre-treatment with two known neuroprotective agents: the AMPA/KA blocker CNQX and methylprednisolone. The nuclear markers Propidium iodide and Sytox-green, as well as the TUNEL (in situ terminal deoxytransferase-mediated dUTP nick end labeling) technique, were used as a quantitative indicators of cell death at 24, 48 and 72 h post-injury using a confocal microscope and image analysis software. This novel in vitro model of SCI is easy to reproduce, will facilitate the examination of post-trauma cell death mechanisms and the neuroprotective effects of pharmacological agents and aid in the study of transgenic murine models.