Candidate for the Lee B. Lusted Student Prize Competition
Purpose: To evaluate whether infliximab, a modern off-label biologic, is cost-effective for treating sarcoid posterior uveitis compared to methotrexate and systemtic steroids. Sarcoid posterior uveitis is a progressive eye disease that can lead to blindness if untreated. In recent trials, ophthalmologists have utilized infliximab, a humanized anti-tumor necrosis factor alpha antibody, which can reverse the effects of uveitis. Systemtic steroids and methotrexate are indicated as two current standards of care for sarcoid posterior uveitis.
Method: A semi-Markov model followed patients’ therapy from the onset of sarcoid posterior uveitis using the societal perspective. The lifetime model simulated health states that could lead to successful reversal of uveitis with standard or intensified treatment with systemic steroids, methotrexate, or infliximab. The model included treatment success, death, or side effects (e.g. glaucoma, cataracts, and nausea) after one year of patient follow-up. Probabilities, health utilities, and costs were included in the model based on findings from literature. Costs and effects were discounted at 3% ($US; 2010 values). We conducted univariate sensitivity analyses and threshold analyses for variables with the greatest impact on the model results. A Bayesian multivariate probablistic sensitivity analysis using 10,000 Monte Carlo simulations was also conducted.
Results were interpretted from a predetermined willingness-to-pay of $50,000/QALY. Result: In order of cost, base case results showed systemic steroids most affordable ($26,871; 14.58 QALYs), followed by methotrexate ($40,351; 15.92 QALYs), and then infliximab ($46,547; 15.04 QALYs). Methotrexate was cost-effective compared to steroids, with an incremental cost-effectiveness ratio of $10,053/QALY. Methotrexate dominated infliximab. Univariate sensitivity analyses suggested that the model was sensitive to the utility of a patient’s successful recovery from uveitis (0.84 QALYs). If patients’ health utility after successful recovery is below 0.750, then infliximab has a greater net benefit than methotrexate. The multivariate probabilistic sensitivity analysis showed that methotrexate dominated infliximab in 60% of the simulations. Methotrexate was not cost-effective over steroids in 4% of simulations.
Conclusion: This cost-effectiveness analysis suggests that despite major advances in the use of biologics for treating sight-threatening sarcoid posterior uveitis, methotrexate remains a less expensive and more cost-effective strategy. Methotrexate should be adopted as the standard of care for treatment considering its incremental cost-effectiveness at a reasonable willingness-to-pay. Other therapeutic options, such as infliximab, may be considered for certain cases.
See more of: The 33rd Annual Meeting of the Society for Medical Decision Making