Biologic treatment sequences for plaque psoriasis: a cost–utility analysis based on 10 years of Dutch real‐world evidence from BioCAPTURE

Summary Background Treatment with biologics may be indicated for patients with moderate‐to‐severe plaque psoriasis, but comparative evidence on cost‐effectiveness is limited. Switching of biologics is common, but it is unclear what the effect is of differences in sequences of biologics. Objectives To evaluate the cost‐effectiveness of different biologic treatment sequences for psoriasis based on real‐world evidence. Patients and methods A sequence model was developed to evaluate the costs and health effects of three consecutive lines of biologic treatments [for example adalimumab–etanercept–ustekinumab (Ada‐Eta‐Ust) vs. Eta‐Ust‐Ada] over a 10‐year time horizon in the Netherlands. The model was populated with data from the Dutch BioCAPTURE registry and scientific literature. Analyses were conducted of cost per quality‐adjusted life year (QALY) and uncertainty was addressed by probabilistic as well as scenario analyses. Results Treatment of psoriasis with biologics for a 10‐year period was estimated to be associated with a cost of €141 962 to €148 442 per patient depending on the treatment sequence used. Cumulative health effects ranged from 7·79 to 8·03 QALYs. Starting with Ada or Ust seems favourable concerning cost and utilities compared with strategies starting with Eta, although credible intervals were partly overlapping. Conclusions The order in which biologics are used influences treatment cost‐effectiveness, both in terms of costs and health effects. Initiation of a biologic treatment sequence for psoriasis might best be done with Ada or Ust; Eta seems less optimal from a health‐economic perspective. What's already known about this topic? Cost–utility studies comparing different biologics for the treatment of psoriasis are rare and are limited to comparisons between single biologics. Ustekinumab (Ust) has a favourable cost–utility compared with etanercept (Eta) as demonstrated by data from the ACCEPT trial; the comparison to adalimumab (Ada) is less clear. What does this study add? This study evaluates cost–utility of biologic sequences in psoriasis instead of individual biologics, using a model based on real‐world evidence. Ada or Ust can best be used as the first biologic; starting with Eta seems less optimal from a health‐economic perspective. As the sequence order of biologics influences both costs and health effects of psoriasis treatment, adopting a long‐term perspective at the start of treatment is of importance. Linked Editorial: Bray and Wol