Clinical outcomes and cost-effectiveness of DMARD therapy in rheumatoid arthritis: a real-world study from rural and urban India

Background. Rheumatoid arthritis (RA) is a chronic, progressive inflammatory disease that imposes a significant clinical and economic burden, particularly in resource-limited settings. Disease-modifying antirheumatic drugs (DMARDs) are the cornerstone of RA management, yet data on their cost-effectiveness in real-world Indian populations remain limited. Objectives. To evaluate the clinical outcomes and cost-effectiveness of various DMARD regimens in a real-world Indian cohort and assess the influence of treatment adherence, functional disability, and socioeconomic factors. Methods. This prospective observational study enrolled 185 RA patients at a tertiary care hospital in Southern India between September 2023 and May 2024. Disease activity was assessed using the Disease Activity Score-28 (DAS-28), functional disability with the Indian Health Assessment Questionnaire–Disability Index (HAQ-DI), and adherence with the Compliance Questionnaire for Rheumatology-5 (CQR-5). Direct medical costs were calculated from the patient perspective, and average cost-effectiveness ratios (ACERs) were determined for each regimen. Results. The cohort was predominantly female (90.8%) with a mean age of 50.4 ± 11.8 years. Methotrexate was the most prescribed and least expensive DMARD (INR 2,567 [$30] per 3 months), while leflunomide–tofacitinib was the most costly (INR 11,367 [$134]). The triple regimen of methotrexate, hydroxychloroquine, and tofacitinib was the most cost-effective. High adherence (≥80%) was seen in 92% of patients and correlated with improved DAS-28 scores. Socioeconomic disparities were linked to baseline disease severity. Conclusions. In this resource-limited setting, optimized DMARD therapy, particularly a novel triple-drug combination, can be a cost-effective strategy for improving RA outcomes. High patient adherence is critical for success, underscoring the need for policy interventions to ensure equitable access to effective treatments.