{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,21]],"date-time":"2025-08-21T18:11:14Z","timestamp":1755799874826,"version":"3.44.0"},"reference-count":74,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,8,20]],"date-time":"2025-08-20T00:00:00Z","timestamp":1755648000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:p>Rheumatoid arthritis is a chronic inflammatory joint disease with low treatment coverage in sub-Saharan Africa. Effective treatment strategies are available. We aimed to evaluate the cost effectiveness of six disease modifying anti-rheumatic drug (DMARD) treat-to-target treatment strategies for patients with rheumatoid arthritis in Zanzibar. A Markov model was used to calculate the cost-effectiveness of various DMARD strategies in the treatment of rheumatoid arthritis over a 3-year period. A health-provider perspective was used and only outpatient costs were considered. The Clinical Disease Activity Index (CDAI) was utilized for measurement of efficacy and values were obtained from literature. Quality Adjusted Life Years (QALYs) were obtained from 122 patients attending the rheumatology clinic at Mnazi Mmoja Hospital. Data on costs were obtained from the central medical stores and hospital administration. Treatment strategies were given in sequential approach based on treat to target goals of therapy. This included methotrexate monotherapy, methotrexate\u202f+\u202fsulfasalazine\u202f+\u202fhydroxychloroquine, methotrexate followed by one or two biologic\/targeted-synthetic DMARDs (b\/tsDMARDs). Probabilistic and one way sensitivity analysis were performed. Scenario analysis was undertaken comparing drug prices from India and Scandinavia. Costs of therapy\/patient\/3 years ranged from USD 634 for methotrexate monotherapy and USD 5011 for methotrexate and two consecutive b\/tsDMARDs. The highest and lowest effects were 2.209 and 2.079 QALYs gained from methotrexate therapy\u202f+\u202ftwo consecutive b\/tsDMARDs and methotrexate monotherapy, respectively. From a healthcare provider perspective methotrexate monotherapy was the cost-effective option at a willingness to pay of USD 282. Pairwise comparison also favored methotrexate monotherapy as the feasible option. We found that increasing the willingness to pay led to a change in the most acceptable option from methotrexate monotherapy to methotrexate followed by b\/tsDMARD. Methotrexate monotherapy is the cost-effective option for the management of rheumatoid arthritis in Zanzibar. Other options may be feasible if the willingness to pay threshold is increased or the drug prices are lowered, particularly for the b\/tsDMARDs.<\/jats:p>","DOI":"10.3389\/fmed.2025.1618493","type":"journal-article","created":{"date-parts":[[2025,8,20]],"date-time":"2025-08-20T05:35:21Z","timestamp":1755668121000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Treating rheumatoid arthritis in Zanzibar: a cost effectiveness study comparing conventional, biologic, and targeted-synthetic disease modifying anti-rheumatic drugs"],"prefix":"10.3389","volume":"12","author":[{"given":"Sanaa S.","family":"Said","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Melf-Jakob","family":"K\u00fchl","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bjorg-Tilde Svanes","family":"Fevang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tone Wikene","family":"Nystad","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kjell Arne","family":"Johansson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2025,8,20]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"863","DOI":"10.1007\/s00296-020-04731-0","article-title":"The global prevalence of rheumatoid arthritis: a meta-analysis based on a systematic review","volume":"41","author":"Almutairi","year":"2021","journal-title":"Rheumatol Int"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"5","DOI":"10.7189\/jogh.05.010409","article-title":"Prevalence of rheumatoid arthritis in low\u2013 and middle\u2013income countries: a systematic review and analysis","author":"Rudan","year":"2015","journal-title":"J Glob Health"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"104689","DOI":"10.1016\/j.amsu.2022.104689","article-title":"The outlook of rheumatological care in Africa: current state, challenges, and recommendation","volume":"82","author":"Nicholas","year":"2022","journal-title":"Ann Med Surg"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"469","DOI":"10.1016\/j.berh.2011.10.009","article-title":"Co-morbidities in established rheumatoid arthritis","volume":"25","author":"Gullick","year":"2011","journal-title":"Best Pract Res Clin Rheumatol"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"e594","DOI":"10.1016\/S2665-9913(23)00211-4","article-title":"Global, regional, and national burden of rheumatoid arthritis, 1990\u20132020, and projections to 2050: a systematic analysis of the global burden of disease study 2021","volume":"5","author":"Black","year":"2023","journal-title":"Lancet Rheumatol"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"1291","DOI":"10.3390\/jcm12041291","article-title":"The burden of rheumatoid arthritis: findings from the 2019 global burden of diseases study and forecasts for 2030 by Bayesian age-period-cohort analysis","volume":"12","author":"Cai","year":"2023","journal-title":"J Clin Med"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"492","DOI":"10.1136\/annrheumdis-2013-204573","article-title":"EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update","volume":"73","author":"Smolen","year":"2014","journal-title":"Ann Rheum Dis"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1136\/annrheumdis-2015-207524","article-title":"Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force","volume":"75","author":"Smolen","year":"2016","journal-title":"Ann Rheum Dis"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"i4205","DOI":"10.1136\/bmj.i4205","article-title":"Ultrasound in management of rheumatoid arthritis: ARCTIC randomised controlled strategy trial","volume":"354","author":"Haavardsholm","year":"2016","journal-title":"BMJ"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"519","DOI":"10.2147\/JIR.S219586","article-title":"JAK Inhibitors in rheumatoid arthritis: An evidence-based review on the emerging clinical data","volume":"13","author":"Harrington","year":"2020","journal-title":"J Inflamm Res"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"363","DOI":"10.1038\/s41584-021-00603-4","article-title":"Rheumatic diseases in Africa","volume":"17","author":"Adelowo","year":"2021","journal-title":"Nat Rev Rheumatol"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"e16635","DOI":"10.1097\/MD.0000000000016635","article-title":"Cost-effectiveness analysis of etanercept plus methotrexate vs triple therapy in treating Chinese rheumatoid arthritis patients","volume":"99","author":"Shi","year":"2020","journal-title":"Medicine (Baltimore)"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"845496","DOI":"10.1155\/2011\/845496","article-title":"Cost effectiveness analysis of disease-modifying antirheumatic drugs in rheumatoid arthritis. A systematic review literature. Int","volume":"2011","author":"Benucci","year":"2011","journal-title":"J Rheumatol"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12911-021-01449-2","article-title":"The efficacy, safety and cost-effectiveness of hydroxychloroquine, sulfasalazine, methotrexate triple therapy in preventing relapse among patients with rheumatoid arthritis achieving clinical remission or low disease activity: the study protocol of a randomized controlled clinical trial (ESCoRT study)","volume":"21","author":"Zhao","year":"2021","journal-title":"BMC Med Inform Decis Mak"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"787","DOI":"10.1007\/s00296-020-04762-7","article-title":"One-year direct costs of biological therapy in rheumatoid arthritis and its predictive factors: data from the Moroccan RBSMR registry","volume":"41","author":"Fellous","year":"2021","journal-title":"Rheumatol Int"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"e34664","DOI":"10.7759\/cureus.34664","article-title":"The cost-effectiveness of and adherence to disease-modifying antirheumatic drug (DMARD) therapy in rheumatoid arthritis patients in a tertiary care teaching Hospital in Uttarakhand, India","volume":"15","author":"Mittal","year":"2023","journal-title":"Cureus"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"13","DOI":"10.1186\/s12962-022-00347-2","article-title":"Pharmacoeconomic analysis of biologics and methotrexate for rheumatoid arthritis from the standpoint of the number needed to treat concept under the Japanese health insurance system","volume":"20","author":"Harigane","year":"2022","journal-title":"Cost Eff Resour Alloc."},{"key":"ref18","doi-asserted-by":"publisher","first-page":"395","DOI":"10.2147\/CEOR.S201621","article-title":"Cost-effectiveness analysis of baricitinib versus adalimumab for the treatment of moderate-to-severe rheumatoid arthritis in Spain","volume":"11","author":"Schlueter","year":"2019","journal-title":"Clin Outcomes Res"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"1367","DOI":"10.1093\/rheumatology\/41.12.1367","article-title":"The rheumatoid arthritis patient in the clinic: comparing more than 1300 consecutive DMARD courses","volume":"41","author":"Aletaha","year":"2002","journal-title":"Rheumatology"},{"key":"ref20","article-title":"Chapter 51 cost-effectiveness of interventions for musculoskeletal conditions","volume-title":"Disease control priorities in developing countries 2nd edition","author":"Connelly","year":"2004"},{"volume-title":"Clinical guidelines for management and referral of common conditions at level 4\u20136 hospitals","year":"2009","key":"ref21"},{"volume-title":"Hospital level (adults) standard treatment guidelines and essential medicines list for South Africa","year":"2019","key":"ref22"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"685","DOI":"10.1136\/annrheumdis-2019-216655","article-title":"EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update","volume":"79","author":"Smolen","year":"2020","journal-title":"Ann Rheum Dis"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"2316","DOI":"10.1002\/1529-0131(200010)43:10<2316::AID-ANR20>3.0.CO;2-6","article-title":"A COST-effectiveness analysis of treatment options for patients with methotrexate-resistant rheumatoid arthritis","volume":"43","author":"Choi","year":"2000","journal-title":"Arthritis Rheum"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"23","DOI":"10.1186\/s12916-021-02204-0","article-title":"Consolidated health economic evaluation reporting standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations","volume":"20","author":"Husereau","year":"2022","journal-title":"BMC Med"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"1011","DOI":"10.2165\/00019053-200624100-00008","article-title":"The initial validation of a Markov model for the economic evaluation of (new) treatments for rheumatoid arthritis","volume":"24","author":"Welsing","year":"2006","journal-title":"PharmacoEconomics"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"1320","DOI":"10.1093\/rheumatology\/ker084","article-title":"Treatment strategies aiming at remission in early rheumatoid arthritis patients: starting with methotrexate monotherapy is cost-effective","volume":"50","author":"Schipper","year":"2011","journal-title":"Rheumatology"},{"key":"ref28","article-title":"Treatment of rheumatoid arthritis","volume-title":"Kelley\u2019s textbook of rheumatology","author":"Saunders","year":"2013"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"e76","DOI":"10.1136\/ard-2022-223356corr1","article-title":"EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update","volume":"82","author":"Smolen","year":"2023","journal-title":"Ann Rheum Dis"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"1241","DOI":"10.1002\/art.41301","article-title":"American College of Rheumatology Guidance for the Management of Rheumatic Disease in adult patients during the COVID-19 pandemic: version 1","volume":"72","author":"Mikuls","year":"2020","journal-title":"Arthritis Rheumatol"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"715","DOI":"10.1002\/acr2.11200","article-title":"Trends in hospitalization rates, major causes of hospitalization, and in-hospital mortality in rheumatoid arthritis in the United States from 2000 to 2014","volume":"2","author":"Iyer","year":"2020","journal-title":"ACR Open Rheumatol"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"e2536","DOI":"10.7196\/SAMJ.2025.v115i4.2536","article-title":"Leflunomide as an alternative csDMARD for rheumatoid arthritis in a resource-constrained setting: a real-life experience","volume":"115","author":"Mkhize","year":"2025","journal-title":"South African Med J"},{"key":"ref33","article-title":"Rheumatology advisor","volume-title":"Treatment with b\/ts DMARDs moderately increases the risk for nonserious infections in Spondyloarthritis","author":"Kurek","year":"2024"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"417","DOI":"10.1093\/rheumatology\/kew442","article-title":"Risk of serious adverse effects of biological and targeted drugs in patients with rheumatoid arthritis: a systematic review meta-analysis","volume":"56","author":"Tarp","year":"2017","journal-title":"Rheumatology"},{"key":"ref35","first-page":"3","article-title":"Establishing rheumatoid arthritis Care in Zanzibar: a year of clinical outcomes and challenges","volume-title":"Journal of Kenya Association of Physicians (JOKAP)","author":"Said","year":"2025"},{"volume-title":"Tanzania Medical Stores Department","year":"","key":"ref36"},{"volume-title":"National Pharmaceutical Pricing Authority","year":"","key":"ref37"},{"volume-title":"Online Pharmacy India","year":"2023","key":"ref38"},{"volume-title":"Indian Online Pharmacy","year":"2023","key":"ref39"},{"article-title":"Evidence brief: epilepsy, treatment FairChoices DCP analytics tool epilepsy, diagnostics and treatment","year":"2021","author":"Hubbers","key":"ref40"},{"key":"ref41","doi-asserted-by":"publisher","first-page":"e000993","DOI":"10.1136\/rmdopen-2019-000993","article-title":"Low rates of remission with methotrexate monotherapy in rheumatoid arthritis: review of randomised controlled trials could point towards a paradigm shift","volume":"5","author":"Chatzidionysiou","year":"2019","journal-title":"RMD Open"},{"key":"ref42","doi-asserted-by":"publisher","first-page":"682","DOI":"10.1093\/rheumatology\/keaa259","article-title":"Effect of disease duration and other characteristics on efficacy outcomes in clinical trials of tocilizumab for rheumatoid arthritis","volume":"60","author":"Rubbert-Roth","year":"2021","journal-title":"Rheumatology"},{"key":"ref43","doi-asserted-by":"publisher","first-page":"e000232","DOI":"10.1136\/rmdopen-2015-000232","article-title":"Original article: relationship between clinical and patient-reported outcomes in a phase 3 trial of tofacitinib or MTX in MTX-na\u00efve patients with rheumatoid arthritis","volume":"2","author":"Fleischmann","year":"2016","journal-title":"RMD Open"},{"key":"ref44","doi-asserted-by":"publisher","first-page":"1114","DOI":"10.1002\/acr.24253","article-title":"Real-world outcomes associated with methotrexate, sulfasalazine, and hydroxychloroquine triple therapy versus tumor necrosis factor inhibitor\/methotrexate combination therapy in patients with rheumatoid arthritis","volume":"73","author":"Curtis","year":"2021","journal-title":"Arthritis Care Res"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"4178","DOI":"10.3390\/jcm11144178","article-title":"Effectiveness of golimumab as second anti-TNF\u03b1 drug in patients with rheumatoid arthritis, psoriatic arthritis and axial Spondyloarthritis in Italy: GO-BEYOND, a prospective real-world observational study","volume":"11","author":"D\u2019Angelo","year":"2022","journal-title":"J Clin Med"},{"key":"ref46","doi-asserted-by":"publisher","first-page":"1671","DOI":"10.1136\/annrheumdis-2019-eular.417","article-title":"AB0417 efficacy and safety of tofacitinib in patients with rheumatoid arthritis according to duration of prior CSDMARD treatment and number of prior CSDMARDS: a post hoc analysis of phase 3 and phase 3B\/4 trials","volume":"78","author":"Aletaha","year":"2019","journal-title":"Ann Rheum Dis"},{"key":"ref47","doi-asserted-by":"publisher","first-page":"81","DOI":"10.1186\/s13075-017-1289-x","article-title":"Clinical and demographic factors associated with change and maintenance of disease severity in a large registry of patients with rheumatoid arthritis","volume":"19","author":"Reed","year":"2017","journal-title":"Arthritis Res Ther"},{"volume-title":"Life expectancy","year":"","key":"ref48"},{"key":"ref49","doi-asserted-by":"publisher","first-page":"871","DOI":"10.1016\/j.berh.2007.05.003","article-title":"Mortality in established rheumatoid arthritis","volume":"21","author":"Naz","year":"2007","journal-title":"Best Pract Res Clin Rheumatol"},{"key":"ref50","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1093\/bmb\/ldq033","article-title":"Health outcomes in economic evaluation: the QALY and utilities","volume":"96","author":"Whitehead","year":"2010","journal-title":"Br Med Bull"},{"key":"ref51","doi-asserted-by":"publisher","first-page":"309","DOI":"10.1007\/s40273-021-01101-x","article-title":"Developing the EQ-5D-5L value set for Uganda using the \u2018lite\u2019 protocol","volume":"40","author":"Yang","year":"2022","journal-title":"PharmacoEconomics"},{"key":"ref52","doi-asserted-by":"publisher","first-page":"157","DOI":"10.20471\/acc.2019.58.01.20","article-title":"Quality of LIFE in patients with rheumatoid arthritis - a preliminary study","volume":"58","author":"Martinec","year":"2019","journal-title":"Acta Clin Croat"},{"key":"ref53","doi-asserted-by":"publisher","first-page":"304","DOI":"10.4103\/err.err_39_19","article-title":"Impact of rheumatoid arthritis on the quality of life and its relation to disease activity","volume":"46","author":"Goma","year":"2019","journal-title":"Egypt Rheumatol Rehabil"},{"key":"ref54","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1016\/B978-0-7020-4084-9.00044-6","article-title":"Chapter 5 - health technology assessment","volume-title":"Clinical Pharmacology","author":"Rawlins","year":"2012"},{"key":"ref55","doi-asserted-by":"publisher","first-page":"e833","DOI":"10.1016\/S2214-109X(23)00162-6","article-title":"Determining the efficiency path to universal health coverage: cost-effectiveness thresholds for 174 countries based on growth in life expectancy and health expenditures","volume":"11","author":"Pichon-Riviere","year":"2023","journal-title":"Lancet Glob Health"},{"volume-title":"Treat-to-target: Rheumatoid arthritis in adults: Diagnosis and management","year":"2018","key":"ref56"},{"key":"ref57","doi-asserted-by":"publisher","first-page":"838","DOI":"10.1007\/s42399-021-00727-4","article-title":"Treat-to-target strategies in rheumatoid arthritis: a systematic review and cost-effectiveness analysis","volume":"3","author":"Hock","year":"2021","journal-title":"SN Compr Clin Med"},{"key":"ref58","doi-asserted-by":"publisher","first-page":"268","DOI":"10.1111\/1756-185X.12320","article-title":"Challenges and opportunities in the early diagnosis and optimal management of rheumatoid arthritis in Africa and the Middle East","volume":"18","author":"Halabi","year":"2015","journal-title":"Int J Rheum Dis"},{"key":"ref59","doi-asserted-by":"publisher","first-page":"1777","DOI":"10.3899\/jrheum.160303","article-title":"Active rheumatoid arthritis in Central Africa: a comparative study between Sudan and Sweden","volume":"43","author":"Elshafie","year":"2016","journal-title":"J Rheumatol"},{"key":"ref60","doi-asserted-by":"publisher","first-page":"97","DOI":"10.1007\/s40261-022-01238-3","article-title":"Cost effectiveness of rituximab therapy for rheumatoid arthritis: a systematic review and Meta-analysis of cost-utility studies","volume":"43","author":"Kumar","year":"2023","journal-title":"Clin Drug Investig"},{"key":"ref61","doi-asserted-by":"publisher","first-page":"461","DOI":"10.1016\/j.jval.2019.12.003","article-title":"Economic evaluation of sequences of biological treatments for patients with moderate-to-severe rheumatoid arthritis and inadequate response or intolerance to methotrexate in France","volume":"23","author":"Ghabri","year":"2020","journal-title":"Value Heal J Int Soc Pharmacoeconomics Outcomes Res"},{"key":"ref62","doi-asserted-by":"publisher","first-page":"302","DOI":"10.1093\/mr\/roac038","article-title":"Cost-effectiveness analyses of biologic and targeted synthetic disease-modifying anti-rheumatic diseases in patients with rheumatoid arthritis: three approaches with a cohort simulation and real-world data","volume":"33","author":"Kuwana","year":"2023","journal-title":"Mod Rheumatol"},{"key":"ref63","doi-asserted-by":"publisher","first-page":"61","DOI":"10.1007\/s10198-007-0089-7","article-title":"The burden of rheumatoid arthritis and access to treatment: uptake of new therapies","volume":"8","author":"J\u00f6nsson","year":"2008","journal-title":"Eur J Health Econ"},{"key":"ref64","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12913-021-07425-w","article-title":"Exploring drug cost and disease outcome in rheumatoid arthritis patients treated with biologic and targeted synthetic DMARDs in Norway in 2010\u20132019 \u2013 a country with a national tender system for prescription of costly drugs","volume":"22","author":"Brkic","year":"2022","journal-title":"BMC Health Serv Res"},{"key":"ref65","doi-asserted-by":"publisher","first-page":"573","DOI":"10.2147\/CEOR.S140063","article-title":"Drug tendering: drug supply and shortage implications for the uptake of biosimilars","volume":"9","author":"Dranitsaris","year":"2017","journal-title":"Clinicoecon Outcomes Res"},{"key":"ref66","doi-asserted-by":"publisher","first-page":"e2219503","DOI":"10.1001\/jamanetworkopen.2022.19503","article-title":"Appraising drugs based on cost-effectiveness and severity of disease in Norwegian drug coverage decisions","volume":"5","author":"Tranv\u00e5g","year":"2022","journal-title":"JAMA Netw Open"},{"key":"ref67","doi-asserted-by":"publisher","first-page":"1195","DOI":"10.1007\/s10067-014-2690-3","article-title":"Rheumatoid arthritis in the developing world: stepping up to the challenge","volume":"33","author":"Hodkinson","year":"2014","journal-title":"Clin Rheumatol"},{"volume-title":"Zanzibar essential health care package report","year":"2022","key":"ref68"},{"key":"ref69","doi-asserted-by":"publisher","first-page":"1759720X20937132","DOI":"10.1177\/1759720X20937132","article-title":"Treatment patterns and achievement of the treat-to-target goals in a real-life rheumatoid arthritis patient cohort: data from 1317 patients","volume":"12","author":"Thomas","year":"2020","journal-title":"Ther Adv Musculoskelet Dis"},{"key":"ref70","doi-asserted-by":"publisher","first-page":"84","DOI":"10.1186\/s13075-025-03528-5","article-title":"Achievement of treatment targets and maintenance of response with upadacitinib in patients with moderate-to-severe rheumatoid arthritis in real-world practice: 1-year outcomes from the UPHOLD observational study","volume":"27","author":"\u00d6st\u00f6r","year":"2025","journal-title":"Arthritis Res Ther"},{"key":"ref71","doi-asserted-by":"publisher","first-page":"1575","DOI":"10.1007\/s40744-023-00597-3","article-title":"Comparative effectiveness, time to discontinuation, and patient-reported outcomes with baricitinib in rheumatoid arthritis: 2-year data from the multinational, prospective observational RA-BE-REAL study in European patients","volume":"10","author":"Alten","year":"2023","journal-title":"Rheumatol Ther"},{"key":"ref72","doi-asserted-by":"publisher","first-page":"482","DOI":"10.1080\/14397595.2017.1361893","article-title":"Productivity loss of Japanese patients with rheumatoid arthritis \u2013 a cross-sectional survey","volume":"28","author":"Sruamsiri","year":"2018","journal-title":"Mod Rheumatol"},{"key":"ref73","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1186\/s12962-019-0174-7","article-title":"Cost effectiveness and affordability of trastuzumab in sub-Saharan Africa for early stage HER2-positive breast cancer","volume":"17","author":"Gershon","year":"2019","journal-title":"Cost Eff Resour Alloc"},{"key":"ref74","doi-asserted-by":"publisher","first-page":"e000259","DOI":"10.1136\/rmdopen-2016-000259","article-title":"Costs of drugs for treatment of rheumatic diseases","volume":"2","author":"Westhovens","year":"2016","journal-title":"RMD Open"}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2025.1618493\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,20]],"date-time":"2025-08-20T05:35:24Z","timestamp":1755668124000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2025.1618493\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8,20]]},"references-count":74,"alternative-id":["10.3389\/fmed.2025.1618493"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2025.1618493","relation":{},"ISSN":["2296-858X"],"issn-type":[{"type":"electronic","value":"2296-858X"}],"subject":[],"published":{"date-parts":[[2025,8,20]]},"article-number":"1618493"}}