Cost-Utility and Budget Impact Analysis of Tumor Necrosis Factor-Alpha Inhibitors for the Treatment of Refractory Nonsystemic Juvenile Idiopathic Arthritis in Thailand

Objectives To evaluate the cost-utility and budget impact of introducing individual tumor necrosis factor-alpha inhibitors, including adalimumab, etanercept, infliximab, and golimumab, as add-on therapies for patients aged 2 years or older with refractory nonsystemic juvenile idiopathic arthritis in Thailand. Methods Decision-tree and Markov models were used to conduct a cost-utility analysis from a societal perspective to estimate lifetime costs and health outcomes. Direct medical and nonmedical costs were obtained from a hospital database and a previous study, respectively. Health-related quality of life (QALY) was measured using the proxy child-friendly EQ-5D and a visual analog scale. Costs and outcomes were discounted at 3% per year. Results are presented as incremental cost-effectiveness ratios (ICERs) in Thai Baht (THB). Sensitivity analyses were conducted to assess parameter uncertainty, and a 5-year budget impact analysis was performed from a governmental perspective. Results Adalimumab demonstrated the lowest ICER (205 012-205 225 THB/QALY), followed by infliximab (441 077-640 657), etanercept (2 134 756-2 280 312), and golimumab (93 198 577). Price reductions of 28% for adalimumab and 43% to 74% for infliximab are required to meet the Thai cost-effectiveness threshold of 160 000 THB/QALY. For the base-case analysis, the 5-year budget impact of infliximab (175-244 million THB) was similar to that of adalimumab (239 million THB), whereas adalimumab achieved greater QALY gains (1.97 vs 0.76). Conclusions Although none of the tumor necrosis factor-alpha inhibitors were cost-effective at the current Thai threshold, adalimumab yielded the most favorable ICER among the evaluated options, whereas infliximab offered a lower budget impact at threshold prices.