Maxime Verhoeven

224 Chapter 13 outcomes over the first 2 years showed that the strategies initiating TCZ yielded the most clinical benefit, over the longer-term differences, in disease activity, physical function and radiographic progression between the strategies faded. Next to longer-term effectiveness of treatment, the cost-effectiveness is of relevance to implementation of treatment strategies. The research question of chapter 7 was to evaluate the cost effectiveness over 5 years of treat-to-target treatment strategies in early DMARD-naïve RA patients initiating TCZ with or without MTX versus initiating MTX as monotherapy. Our analyses indicated that early initiation of TCZ or TCZ+MTX was not cost-effective compared with MTX initiation in a treat-to-target treatment strategy over 5 years in early RA patients. Sensitivity and scenario analyses showed that lower-priced TCZ improved cost effectiveness for the TCZ-based strategies, as well as reserving the TCZ-based strategies for patients anticipated (predicted) not to respond sufficiently to MTX. Although, this did not lead to the TCZ-based strategies being cost-effective. The final chapter, chapter 8 , of part I is an editorial entitled “Unravelling the cost of biological strategies in rheumatoid arthritis: a kaleidoscope of methodologies, interpretations and interests”, and is a discussion of, and response to a paper on the budget impact of introducing an etanercept biosimilar in a single rheumatology centre. 6 The paper showed that costs of bDMARDs decreased but this advantage was lost within less than a year, due to an increase of the percentage of the patients with RA treated with a bDMARD. We concluded that with a different, explicit strategy for prescribing bDMARD or a broader scope of the cost(-effectiveness) study, a different conclusion might have been reached. We stressed the importance to continue conducting health-economic evaluations of current and novel DMARD strategies, including those investigating in whom, and when to initiate, taper and discontinue bDMARD treatment. Proper implementation of and adherence to these strategies in clinical practice are important for improvement of patients’ health and control of heath care costs. Summary of PART II of the thesis A good measuring instrument to monitor disease activity should be able to detect changes in disease activity within individual patients, the study described in chapter 9 was performed to determine the ability of the HandScan (an objective surrogate for measuring joint inflammation) to longitudinally measure RA disease activity using DAS28 as reference (being the current standard method for measuring disease activity within patients). Based on the results we concluded that a longitudinal association of optical spectral transmission (OST-)score (obtained by the HandScan) with DAS28 exists, although it is weak. Results indicate that the HandScan may have potential as monitoring instrument for RA, but that it likely performs better when combined with other disease activity parameters for a comprehensive view of RA disease activity. For that reason, we aimed