BackgroundInflammatory bowel disease (IBD) is a chronic disease placing a large health and economic burden on health systems worldwide. The treatment landscape is complex with multiple strategies to induce and maintain remission while avoiding long-term complications. The extent to which rising treatment costs, due to expensive biologic agents, are offset by improved outcomes and fewer hospitalisations and surgeries needs to be evaluated. This systematic review aimed to assess the cost-effectiveness of treatment strategies for IBD.Materials and methodsA systematic literature search was performed in March 2017 to identify economic evaluations of pharmacological and surgical interventions, for adults diagnosed with Crohn’s disease (CD) or ulcerative colitis (UC). Costs and incremental cost-effectiveness ratios (ICERs) were adjusted to reflect 2015 purchasing power parity (PPP). Risk of bias assessments and a narrative synthesis of individual study findings are presented.ResultsForty-nine articles were included; 24 on CD and 25 on UC. Infliximab and adalimumab induction and maintenance treatments were cost-effective compared to standard care in patients with moderate or severe CD; however, in patients with conventional-drug refractory CD, fistulising CD and for maintenance of surgically-induced remission ICERs were above acceptable cost-effectiveness thresholds. In mild UC, induction of remission using high dose mesalazine was dominant compared to standard dose. In UC refractory to conventional treatments, infliximab and adalimumab induction and maintenance treatment were not cost-effective compared to standard care; however, ICERs for treatment with vedolizumab and surgery were favourable.ConclusionsWe found that, in general, while biologic agents helped improve outcomes, they incurred high costs and therefore were not cost-effective, particularly for use as maintenance therapy. The cost-effectiveness of biologic agents may improve as market prices fall and with the introduction of biosimilars. Future research should identify optimal treatment strategies reflecting routine clinical practice, incorporate indirect costs and evaluate lifetime costs and benefits.

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Background This study aimed to evaluate the clinical outcomes for adults diagnosed with Crohn’s disease (CD) who started biologic treatments within 2 years of diagnosis (early initiation) compared with those who started biologics >2 years after diagnosis or who did not receive any biologic treatment during the period of observation (late/no biologic initiation). Methods We conducted a retrospective analysis using 10 years of follow-up data from patients included in a national cohort study. We used propensity score methods to match patients in the early vs. late/no biologic initiation groups based on key baseline patient and clinical characteristics. Kaplan–Meier time-to-event models were used to evaluate the risks of intestinal resection surgery, fistula, stricture, and disease flares for each group. In addition, a subgroup analysis was performed stratifying patients known to have initiated biologic treatments into early (≤2 years after diagnosis) vs. late (>2 years after diagnosis) initiation groups. Results In total, 411 patients were matched in the early initiation (n = 230) vs. late/no initiation (n = 181) groups. Two years after diagnosis, early biologic initiators had a 12% lower probability of intestinal resection surgery, a 9% higher probability of disease flares and fistulae, and a 5% higher probability of strictures compared with the late/no biologic initiators (Figure 1). After 10 years, the overall difference in the cumulative probability for each event were not statistically significant between the two groups. In the subgroup analysis, patients who initiated biologics early had a lower overall probability of stricture (p < 0.01), disease flares (p < 0.01), and intestinal resection surgery (p = 0.72), and a higher probability of fistula (p = 0.74) 10 years after diagnosis when compared with the group of patients who initiated biologics late. Conclusion This study found no significant differences in the long-term cumulative probabilities of intestinal resection surgery, fistula, stricture, and disease flares amongst CD patients who initiated biologic treatment early compared with similar patients who initiated biologic therapy late or who had not started any biologic treatments. However, in a subgroup of patients known to receive biologic treatments, early initiation was associated with significantly lower overall risks of strictures and disease flares. These results highlighted the need for more individualised care in CD in order to target aggressive treatment approaches to patients who show early signs of a complicated disease course.

Background and Aims We evaluated the cost-effectiveness of early [≤2 years after diagnosis] compared with late or no biologic initiation [starting biologics >2 years after diagnosis or no biologic use] for adults with Crohn’s disease in Switzerland. Methods We developed a Markov cohort model over the patient’s lifetime, from the health system and societal perspectives. Transition probabilities, quality of life, and costs were estimated using real-world data. Propensity score matching was used to ensure comparability between patients in the early [intervention] and late/no [comparator] biologic initiation strategies. The incremental cost-effectiveness ratio [ICER] per quality-adjusted life year [QALY] gained is reported in Swiss francs [CHF]. Sensitivity and scenario analyses were performed. Results Total costs and QALYs were higher for the intervention [CHF384 607; 16.84 QALYs] compared with the comparator [CHF340 800; 16.75 QALYs] strategy, resulting in high ICERs [health system: CHF887 450 per QALY; societal: CHF449 130 per QALY]. In probabilistic sensitivity analysis, assuming a threshold of CHF100 000 per QALY, the probability that the intervention strategy was cost-effective was 0.1 and 0.25 from the health system and societal perspectives, respectively. In addition, ICERs improved when we assumed a 30% reduction in biologic prices [health system: CHF134 502 per QALY; societal: intervention dominant]. Conclusions Early biologic use was not cost-effective, considering a threshold of CHF100 000 per QALY compared with late/no biologic use. However, early identification of patients likely to need biologics and future drug price reductions through increased availability of biosimilars may improve the cost-effectiveness of an early treatment approach.