Cost comparison between early intensive and escalating strategies for multiple sclerosis in Brazil

Introduction: The optimal treatment strategy for multiple sclerosis (MS) remains a topic of debate. The classical approach is the escalating (ESC) strategy, which involves initiating treatment with low-to-moderate-efficacy disease-modifying drugs (DMDs) and escalating to high-efficacy DMDs when there is evidence of active disease. Another approach, the early intensive (EIT) strategy, entails starting with high-efficacy DMDs as first-line therapy. However, this approach is limited by safety and cost considerations, particularly in middle-to-low income countries and public health systems. Objective: Our objective was to compare the long-term cost effectiveness of the ESC and EIT strategies, using a cost-effectiveness model tailored to the context of Brazil. Methods: We considered EIT initial strategies with fingolimod, cladribine, natalizumab, alemtuzumab, rituximab, or ocrelizumab. We developed a Markov model with an expected 30% lower increase in EDSS (Expanded Disability Status Scale) in the EIT group, based on a previous meta-analysis conducted by our team. Cost estimates were based on a five-year time horizon, using a previously published EDSS-based model for Brazil, and drug costs were obtained from the official Brazilian government's suggested prices. Results: The drug costs of fingolimod, cladribine, natalizumab, rituximab, and alemtuzumab were similar to the costs of the drugs used in ESC strategies (interferon, glatiramer, teriflunomide, dimethyl fumarate). However, the EIT strategy was associated with an increase in quality-adjusted life years (QALYs) and a reduction of R$2073,00 in non-drug related costs over a five-year time horizon. Conclusion: Our findings suggest that the EIT strategy can be cost-effective in Brazil, particularly when initiated with natalizumab, rituximab, alemtuzumab, fingolimod, or cladribine. This supports the use of the EIT strategy, rather than the ESC strategy, for the treatment of MS in Brazil.