Biologic treatment outcomes in rheumatoid arthritis: Biomarker response and cost-effectiveness analysis in an Albanian cohort

<h2>Abstract</h2><h3>Background</h3> Rheumatoid arthritis (RA) is a chronic autoimmune disease causing progressive joint damage, disability, and high healthcare costs. Biologic DMARDs have improved outcomes, but responses vary. Identifying predictive biomarkers and evaluating cost-effectiveness are essential, particularly in resource-limited settings like Albania. <h3>Methods</h3> A retrospective cohort study at Mother Teresa University Hospital Center, Tirana, included 162 RA patients treated with bDMARDs (2021–2024). All met ACR/EULAR criteria and had biomarker data at baseline and six months. ESR, CRP, fibrinogen, RF, and anti-CCP were analyzed using paired t-tests (p < 0.05). Cost-effectiveness analysis compared direct drug costs with biomarker improvement across adalimumab and tocilizumab using ICERs. <h3>Results</h3> Tocilizumab (46.8%), adalimumab (37.1%), and etanercept (16.1%) were the main bDMARDs used. ESR, CRP, and fibrinogen significantly decreased (p < 0.01). Six-month direct costs were 1,136.20 USD for adalimumab, 2,233.40 USD for etanercept, and 4,069.00 USD for tocilizumab. Adalimumab demonstrated the best cost-effectiveness, with the lowest cost per unit biomarker reduction (ESR 87.40 USD/mm/h; CRP 59.80 USD/mg/L; fibrinogen 1,456.66 USD/g/L). Tocilizumab achieved the greatest biomarker reductions but had the highest price (156.60 USD/unit) and incremental costs, with ICERs of 2,932.80 USD vs. adalimumab, below Albania's 3× GDP threshold (∼21,000 USD) for ESR and CRP, but near/exceeding it for fibrinogen. <h3>Conclusions</h3> Among available biologics, adalimumab shows the most favorable cost-effectiveness, while tocilizumab may be justified in non-responders to TNF inhibitors. Etanercept was considered economically dominated and was not included in the incremental cost-effectiveness analysis. Biomarker-guided assessment supports cost-effective and evidence-based management of RA in Albania.