ORIGINAL RESEARCH

Psoriasis Treatment Cost Comparison:

Biologics Versus Home Phototherapy
Kimberly Hyde, MD; Leah A. Cardwell, MD; Ronnie Stotts, BS; Steven R. Feldman, MD, PhD

P
ABSTRACT soriasis is a chronic inflammatory condition associated
Background: Psoriasis is a chronic inflammatory condition with considerable morbidity and economic burden.
associated with considerable morbidity and economic burden. Approximately 7.5 million adults in the United States
Objectives: To estimate and compare the costs of home are affected by this disorder; about 17% have moderate-to-
phototherapy versus biologics over a 3-year time horizon in severe disease.1–3 Treatment options for moderate-to-severe
patients with moderate to severe plaque psoriasis. psoriasis include phototherapy, oral agents (including
Methods: The biologics compared were adalimumab, etanercept, cyclosporine or methotrexate), and injectable biologics. Home
infliximab, ustekinumab, and secukinumab. Average wholesale phototherapy, perhaps the most cost-effective treatment in
prices of biologics were obtained through Lexicomp. Home the long run, is safe and effective, and incurs relatively few
phototherapy costs were estimated by obtaining quotes from
costs: those of acquiring the equipment, initially, and of bulb
phototherapy device manufacturers. Three-year cost horizon,
3-month cost, and cost per success were calculated. To assess replacement every 3 to 6 years.4 Acquisition of home units
cost-effectiveness, Psoriasis Area Severity Index (PASI) 75 rates is often hindered by qualification protocols defined by each
served as the surrogate for the rate of treatment success. Cost insurance company.5 Even when home units are covered,
per success represents the cost for 3 months of treatment patients’ co-payment requirements may discourage their
relative to the percent of patients who achieved PASI 75.
use, leading many to choose biologics instead.5
Results: Secukinumab is the most expensive biologic with Biologic treatment has revolutionized the care of patients
a 3-year cost of $182,718 compared with a 3-year cost of
with moderate-to-severe psoriasis but is far more costly,
$5,000 for phototherapy.
overall, than other treatments. However, patient co-payments
Limitations: Studies on the efficacy of home phototherapy
for biologics are often significantly less than the start-up
tended to have small sample sizes. Larger studies would be useful
to improve the generalizability of the data. The cost estimates are costs for home phototherapy.6 The increasing cost to manage
an average, which may not accurately represent the costs different psoriasis can largely be attributed to the use of biologics in a
insurance companies negotiate. These limitations were considered relatively small percentage of patients.7 The total economic
to have minimal effect on analysis. burden of psoriasis was estimated to be $112 billion in the
Conclusions: The economic burden of psoriasis is substantial. United States for 2013.8
It is important to consider the costs to the healthcare system To assure good stewardship of medical resources, biologics
over a patient’s lifetime when they start biologics or home should be used only in patients who need them, and appropriate
phototherapy. Phototherapy is an effective and economical
incentives should guide treatment among the available options.
option for the treatment of moderate to severe plaque psoriasis.
Because of the rapid turnover of patients among insurance
Am J Pharm Benefits. 2018;10(1):18-21 providers, a short time horizon may be more appropriate to
assess the relative cost-effectiveness of home phototherapy
versus biologics. The purpose of this study is to estimate and
compare the cost of home phototherapy versus biologics over
a 3-year time horizon in patients with moderate-to-severe
plaque psoriasis.

METHODS
The biologics chosen for this cost analysis were the 5 approved
by the US FDA and the European Medicines Agency as of early

18   The American Journal of Pharmacy Benefits®  |  January/February 2018

 Psoriasis Treatment Cost Comparison: Biologics Versus Home Phototherapy

2016 for the treatment of moderate-to-

severe plaque psoriasis: adalimumab, PRACTICAL IMPLICATIONS
etanercept, infliximab, ustekinumab, ■■ Educate clinicians regarding the cost points of psoriasis treatment options.

and secukinumab (ixekizumab was ■■ Reinforce the idea that home phototherapy is an economical and effective treatment option

approved after the study analyses were for patients with psoriasis.
completed). Average wholesale price ■ ■ Motivate insurance policy change pertaining to home phototherapy approval.
for each biologic was obtained from
Lexicomp, and the dosing informa-
tion reflects the respective manufacturer’s prescribing phototherapy. Secukinumab, the most recently developed
guide (TABLE 1). biologic, is the most expensive, with a 3-year cost of
Cost for home phototherapy was estimated by obtaining $182,718 (TABLE 3). The costs of etanercept, adalimumab,
quotes from phototherapy device manufacturers listed by ustekinumab, and infliximab follow in descending order
the National Psoriasis Foundation. A 6-foot-high panel (Table 3). Infliximab is the least expensive biologic with
containing 8 ultraviolet B lamps is the most commonly the highest percentage of patients achieving PASI 75.
used product for moderate-to-severe psoriasis. To obtain The cost for 3 months of home phototherapy relative
a conservative estimate, the most expensive home pho- to the percentage of patients who demonstrate clinical
totherapy device quote was used in the comparison with improvement, measured by achieving PASI 75, displays
biologics. The highest quote, which included shipping, higher value-based care than any of the biologics. The
set-up, technical support, and a 3-year warranty, was $5000. incremental cost-effectiveness ratio (ICER) compares the
When considering average treatment for a single person, cost expense to benefit ratios of the various treatments that
know that lamps need to be replaced every 3 to 6 years and are necessary to reach PASI 75. Home phototherapy has
cost about $1000 in total. Therefore, during a 3-year time the lowest cost per 1% of effectiveness over 3 years; it is
horizon, a conservative estimate for home phototherapy is followed by infliximab, which costs $2648 more per 1%
$5000. This value does not include co-payments for office increase in efficacy over a 3-year time period (Table 3).
visits or the cost of electricity because these expenses
were considered to be nominal relative to the startup cost. Doses
Further, office visit costs incurred for patients treated with Initiation dose cost represents the cost for drug initiation by
biologics are similar to those incurred by those treated with dosing guidelines, as described in Table 1. The maintenance
home phototherapy, but often include additional necessary dose total cost is the cost to complete the remainder of 3
monitoring of treatment-related adverse effects. months of therapy after initiation dosing has been satisfied.
Severity of psoriatic disease is
most commonly estimated in clinical Table 1. Treatment Regimens for Moderate-to-Severe Psoriasis15–20
trials by Psoriasis Area Severity Index AWP
(PASI). Outcomes used in many clini- Maintenance (per maintenance
Initial Dose Dose dose value) PASI 75
cal trials include PASI 50, 75, or 90,
40 mg 53.0%
which indicate a 50%, 75%, or 90% Adalimumab 80 mg $2278
Every other week in 12 weeks9
reduction in PASI score. To assess
50 mg 50 mg 49.0%
cost-effectiveness, we used PASI 75 Etanercept $1118
Twice weekly for 3 months Once a week in 12 weeks10
rates as the surrogate for the rate of 5 mg/kg* 5 mg/kg 80.0%
Infliximab $5593
treatment success. The outcome of this At 0, 2, 6 weeks Every 8 weeks in 10 weeks11
cost analysis is cost to the health plan 45 mg 45 mg 66.7%
Ustekinumab $10,112
over a 3-year time horizon. At 0 and 4 weeks Every 12 weeks in 12 weeks12
300 mg 300 mg 75.9%
Secukinumab $4689
Once weekly for 5 weeks Every 4 weeks in 12 weeks13
RESULTS
Active Treatment Maintenance Dose
For initiation and the first 3 months of
treatment, home phototherapy costs Home 10 minutes Less frequent and 40.7%
$0
Phototherapy NB-UVB 2-3x/week lower doses in 13 weeks**14
$13,224 less than adalimumab, the
AWP indicates average wholesale price; NB-UVB, Narrowband-UVB; PASI, Psoriasis Area Severity Index.
least expensive biologic (TABLE 2). Over *We assumed the average person to weigh 87 kg based on data obtained from the ESPRIT registry of patients with
a 3-year time horizon, the biologics moderate-to-severe psoriasis patients who were taking adalimumab.21
**The number of weeks depended on whether the patient was undergoing 3 or 4 treatments per week. The study stopped
cost up to 36 times more than home when patients accrued 46 treatments.14

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Hyde et al

Table 2. Three-Month Costs: Initiation Plus Maintenance at least a few sessions of costly (high co-payment at each
Initiation Maintenance session) and inconvenient outpatient phototherapy because
Dose Cost Dose Total Cost Cost access to home rental equipment may be limited.23-28 Many
(to initiate (to complete at 3
3-month period) 3-month period) months
patients do not have that capability. These challenges,
along with pharmaceutical programs that cover patients’
Adalimumab $4556 $13,668 $18,224
co-payment costs for biologics, largely discourage patients
Etanercept $26,832 $0 $26,832
from seeking home phototherapy.5 From the health plan
Infliximab $16,779 $5593 $22,372
perspective, delaying biologic use for 3 months with a trial
Ustekinumab $20,224 $10,112 $30,336
of home phototherapy is significantly more cost-effective
Secukinumab $23,445 $9378 $32,823
than beginning biologics right away, given that a home
Home phototherapy $5000 $0 $5000
unit costs $5000 and 3 months of biologic maintenance
therapy cost $11,931 on average.

Cost at 3 months represents the sum of the initial dose Limitations

cost and the maintenance dose total cost for the remaining Our analysis has several limitations. The efficacy data
time period. for home phototherapy are reported from a trial in Den-
mark, which did not select specifically for patients with
DISCUSSION moderate-to-severe psoriasis. A subgroup of patients with
The FDA approval of biologics in the treatment of moderate- moderate-to-severe psoriasis responded similarly to the
to-severe plaque psoriasis has revolutionized our approach average patient in the study.14 Studies on the efficacy of
to treating the disease. Our increasing understanding of home phototherapy tended to have small sample sizes.
the pathophysiology of psoriasis has allowed for targeted Additional larger studies would be useful to improve the
therapy through the use of biologics. To ensure that these generalizability of the data. The cost/efficacy comparison
costly drugs are available to patients with recalcitrant was based on PASI 75 for each treatment option, but the
disease, it is best to limit their use in patients whose duration ranged from 10 to 15 weeks rather than an exact
psoriasis is amenable to lower-cost options.7 3 months. The cost estimates are an average, which may
Home phototherapy for treatment of moderate-to-severe not accurately represent the costs negotiated by different
psoriasis is an effective option with increased patient insurance companies. These limitations, however, were
satisfaction and reduced treatment burden relative to considered to have minimal effect on analysis, as the cost
outpatient phototherapy. 14 A trial
of phototherapy had been recom- Table 3. Treatment Costs: 3-Year Time Horizon
mended by the American Academy Cost Over Cost at 3 Cost per ICER vs Home Phototherapy
of Dermatology before the use of   3 Years PASI 75 Months Success (3 years)
biologics. Currently, healthcare
22
Home 40.70%
$5000 $5000 $12,285
utilization management programs phototherapy in 13 weeks13
often discourage patients from trying 80%
Infliximab $109,066 $22,372 $27,965 $2648
home phototherapy use despite the in 10 weeks10
obvious benefit demonstrated by the 66.70%
Ustekinumab $138,342 $30,336 $45,481 $5123
ICER (Table 3). Patients pursuing in 12 weeks11
home phototherapy often face high 53%
Adalimumab $168,572 $18,224 $34,384 $13,299
co-insurance costs for equipment, high in 12 weeks8
up-front costs with uncertainty about 49%
Etanercept $174,500 $26,846 $54,787 $20,421
reimbursement, coverage rejection, in 12 weeks9
and potentially complicated appeal 75.90%
processes to obtain home phototherapy Secukinumab $182,718 $32,823 $43,245 $5054
in 12 weeks12
equipment. Many qualification pro- Costs were calculated by adding the initial dose cost and the maintenance dose total cost for the remainder of the
tocols for a home unit include proof 36-month time period. The 3-month cost represents the sum of the initial dose cost and the maintenance dose total cost
for the remaining time period (Table 2). Cost per success represents the cost for 3 months of treatment relative to the
of phototherapy-responsive disease percent of patients who achieved Psoriasis Area Severity Index (PASI) 75. This was calculated by dividing the 3-month
before considering coverage; in that cost for treatment by the percentage of patients who achieved PASI 75 over that 3-month time period. Incremental cost-
effectiveness ratio was calculated by dividing the difference between cost over 3 years by the difference in PASI 75 for
case, patients would need to undergo each biologic versus home phototherapy.

20   The American Journal of Pharmacy Benefits®  |  January/February 2018

 Psoriasis Treatment Cost Comparison: Biologics Versus Home Phototherapy

difference to payers for home phototherapy versus biologics 8. Brezinski EA, Dhillon JS, Armstrong AW. Economic burden of psoriasis in the
United States: a systematic review. JAMA Dermatol. 2015;151(6):651-658.
is substantial. doi: 10.1001/jamadermatol.2014.3593.
9. Gordon KB, Langley RG, Leonardi C, et al. Clinical response to adalimumab
treatment in patients with moderate to severe psoriasis: double-blind, random-
CONCLUSIONS ized controlled trial and open-label extension study. J Am Acad Dermatol.
The economic burden of psoriasis is substantial. It is impor- 2006;55(4):598-606. doi: 10.1016/j.jaad.2006.05.027.
10. Leonardi CL, Powers JL, Matheson RT, et al; Etanercept Psoriasis Study
tant to consider the cost to the health plan over a patient’s Group. Etanercept as monotherapy in patients with psoriasis. N Engl J Med.
lifetime when they start biologics or home phototherapy. 2003;349(21):2014-2022. doi: 10.1056/NEJMoa030409.
11. Reich K, Nestle FO, Papp K, et al; EXPRESS Study Investigators. Infliximab
The drastic reduction in cost, even in the short run, suggests
induction and maintenance therapy for moderate-to-severe psoriasis: a phase
that home phototherapy should be encouraged. III, multicentre, double-blind trial. Lancet. 2005;366(9494):1367-1374. doi:
10.1016/S0140-6736(05)67566-6.
Center for Dermatology Research, Department of Dermatology, Wake 12. Papp KA, Langley RG, Lebwohl M, et al; PHOENIX 2 Study Investiga-
Forest University School of Medicine, Winston-Salem, North Carolina tors. Efficacy and safety of ustekinumab, a human interleukin-12/23
(KB, LAC, RS, SRF) monoclonal antibody, in patients with psoriasis: 52-week results from a
randomised, double-blind, placebo-controlled trial (PHOENIX 2). Lancet.
Department of Pathology, Wake Forest University School of Medicine, 2008;371(9625):1675-1684. doi: 10.1016/S0140-6736(08)60726-6.
Winston-Salem, North Carolina (SRF) 13. Blauvelt A, Prinz JC, Gottlieb AB, et al; FEATURE Study Group. Secukinumab
Department of Public Health Sciences, Wake Forest University School administration by pre-filled syringe: efficacy, safety and usability results
of Medicine, Winston-Salem, North Carolina (SRF) from a randomized controlled trial in psoriasis (FEATURE). Br J Dermatol.
Funding statement: Center for Dermatology Research was supported in 2015;172(2):484-493. doi: 10.1111/bjd.13348.
part by an unrestricted educational grant from Galderma Laboratories, LP. 14. Koek MB, Buskens E, van Weelden H, Steegmans PH, Bruijnzeel-Koomen
CA, Sigurdsson V. Home versus outpatient ultraviolet B phototherapy for mild to
Role of the funder: There was no role of the funder for this study. severe psoriasis: pragmatic multicentre randomised controlled non-inferiority
Conflict of interest: Kimberly Hyde, Ronnie Stotts, and Leah Cardwell trial (PLUTO study). BMJ. 2009;338:b1542.
have no conflicts of interest to disclose. 15. Adalimumab, etanercept, infliximab, ustekinumab, secukinumab. Lexicomp
Dr Feldman is a speaker for Janssen and Taro. He is a consultant and Online website. lexi.com/lib-ezproxy.tamu.edu:2048/lco/action/doc/retrieve/
speaker for Galderma, Stiefel/GlaxoSmithKline, Abbott Labs, and Leo docid/patch_f/6285. Published 2016. Accessed April 8, 2016.
Pharma Inc. Dr. Feldman has received grants from Galderma, Janssen, 16. Humira [prescribing information]. North Chicago, IL: Abbvie, 2016.
Abbott Labs, Amgen, Stiefel/GlaxoSmithKline, Celgene, and Anacor. He 17. Enbrel [prescribing information]. Thousand Oaks, CA: Amgen, 2016.
is a consultant for Amgen, Baxter, Caremark, Gerson Lehrman Group, 18. Remicade [prescribing information]. Horsham, PA: Janssen Biotech, 2016.
Guidepoint Global, Hanall Pharmaceutical Co Ltd, Kikaku, Lilly, Merck 19. Stelara [prescribing information]. Horsham, PA: Janssen Biotech, 2016.
& Co Inc, Merz Pharmaceuticals, Mylan, Novartis Pharmaceuticals, Pfizer 20. Cosentyx [prescribing information]. East Hanover, NJ: Novartis, 2016.
Inc, Qurient, Suncare Research, and Xenoport. He is on an advisory board 21. Menter A, Thaci D, Papp KA, et al. Five-year analysis from the ESPRIT 10-
for Pfizer Inc. Dr. Feldman is the founder of and holds stock in Causa year postmarketing surveillance registry of adalimumab treatment for moderate
Research and holds stock in and is majority owner in Medical Quality to severe psoriasis. J Am Acad Dermatol. 2015;73(3):410-419.e6. doi:
Enhancement Corporation. He receives royalties from UpToDate and Xlibris. 10.1016/j.jaad.2015.06.038.
22. Menter A, Korman NJ, Elmets CA, et al; American Academy of Dermatology
Corresponding author: Leah A. Cardwell, MD, Department of Work Group. Guidelines of care for the management of psoriasis and psoriatic
Dermatology Wake Forest University School of Medicine 4618 Country arthritis: section 6. Guidelines of care for the treatment of psoriasis and psori-
Club Road Winston-Salem, NC 27104 E-mail: [email protected] atic arthritis: case-based presentations and evidence-based conclusions. J Am
Phone: 313-790-5469; Fax: 336-716-7732; Acad Dermatol. 2011;65(1):137-174. doi: 10.1016/j.jaad.2010.11.055.
23. Phototherapy, photochemotherapy, and excimer laser therapy for
dermatologic conditions - cignaforhcp.cigna.com/public/content/pdf/cover-
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