Upadacitinib for treating moderate to severe rheumatoid arthritis

1 Recommendations

1.1 Upadacitinib, with methotrexate, is recommended as an option for treating active rheumatoid arthritis in adults whose disease has responded inadequately to intensive therapy with a combination of conventional disease-modifying antirheumatic drugs (DMARDs), only if:

1.2 Upadacitinib, with methotrexate, is recommended as an option for treating active rheumatoid arthritis in adults whose disease has responded inadequately to or who cannot have other DMARDs, including at least 1 biological DMARD, only if:

1.3 Upadacitinib, with methotrexate, is recommended as an option for treating active rheumatoid arthritis in adults whose disease has responded inadequately to rituximab and at least 1 biological DMARD, only if:

1.4 Upadacitinib can be used as monotherapy for people who cannot take methotrexate because it is contraindicated or because of intolerance, when the criteria in sections 1.1 and 1.2 are met.

1.5 Continue treatment only if there is a moderate response measured using European League Against Rheumatism (EULAR) criteria at 6 months after starting therapy. After an initial response within 6 months, withdraw treatment if at least a moderate EULAR response is not maintained.

1.6 When using the DAS28, healthcare professionals should take into account any physical, psychological, sensory or learning disabilities, or communication difficulties that could affect the responses to the DAS28 and make any adjustments they consider appropriate.

1.7 These recommendations are not intended to affect treatment with upadacitinib that was started in the NHS before this guidance was published. People having treatment outside these recommendations may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.

Why the committee made these recommendations

Clinical trials show upadacitinib with methotrexate or conventional DMARDs to be more effective than methotrexate or conventional DMARDs for treating moderate to severe active rheumatoid arthritis that has not responded adequately to conventional DMARDs. The trials also show that for treating moderate to severe active rheumatoid arthritis that has not responded adequately to conventional DMARDs, upadacitinib with methotrexate is more effective than adalimumab with methotrexate or placebo with methotrexate.

Because there are no trials comparing upadacitinib with the full range of biological DMARDs, the company did an indirect comparison. This shows that upadacitinib with conventional DMARDs (including methotrexate) or on its own works as well as the biological DMARDs that NICE has already recommended.

Based on the health-related benefits and costs compared with conventional and biological DMARDs, upadacitinib with methotrexate or upadacitinib on its own is recommended only for severe active rheumatoid arthritis, in line with previous recommendations in NICE technology appraisal guidance on:

For moderate active rheumatoid arthritis, the cost-effectiveness modelling is not robust. Also, the cost-effectiveness estimates for upadacitinib are likely to be higher than what NICE considers a cost-effective use of NHS resources. Therefore, upadacitinib with methotrexate or upadacitinib on its own is not recommended for moderate active rheumatoid arthritis.