Infliximab dose escalation vs. initiation of adalimumab for loss of response in Crohn's disease: A cost-effectiveness analysis

Background: Crohn's disease patients who have lost response to 5 mg/kg of infliximab may regain response by increasing the dose of infliximab to 10 mg/kg. Alternatively, adalimumab can be used as a rescue therapy. Aim: To determine whether dose escalation of infliximab was a cost-effective strategy compared with adalimumab initiation after loss of response to 5 mg/kg of infliximab. Methods: A decision-analysis model simulated two cohorts of Crohn's patients: (i) infliximab dose was escalated to 10 mg/kg and (ii) infliximab was discontinued and patients were started on adalimumab. The time horizon was 1 year. One- and two-way sensitivity analyses were performed. Results: The infliximab dose escalation strategy yielded more quality-adjusted life years (0.79) compared with the adalimumab strategy (0.76). The incremental cost-effectiveness ratio was $332 032/quality-adjusted life year. Sensitivity analysis demonstrated that the model findings were robust. The most significant variables were the cost of infliximab and that of adalimumab, such that a reduction in the cost of infliximab by 1/3 resulted in an incremental cost-effectiveness ratio below $80 000/quality-adjusted life year. Conclusion: After a Crohn's patient has lost response to 5 mg/kg of infliximab, dose escalation will yield more quality-adjusted life-year compared with switching to adaliumamb; however, the cost was considerable.