Comparative cost-utility analysis of ixekizumab, tofacitinib, and golimumab in psoriatic arthritis: a real-world Markov model simulation

Psoriatic arthritis (PsA) requires long-term, phenotype-oriented management. This study compared the cost-utility of ixekizumab, tofacitinib, and golimumab using a real-world modeling approach. A 10-year Markov model was developed from the perspective of the Spanish National Health System, informed by three real-world PsA cohorts. Transition probabilities were derived from drug-persistence data. Utilities and direct medical costs were obtained from published sources. Approved dosing, standard treatment durations, and annual cycles were modeled. Main outcomes included total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Scenario analyses evaluated a 20% price reduction and phenotype-specific settings (enthesitis, dactylitis, axial PsA, refractory disease, prior TNFi failure, and relevant comorbidity). All three agents were cost-effective in the base case, with ICERs below the €30,000/QALY threshold. Ixekizumab provided the highest QALYs and was most cost-effective in axial PsA, enthesitis, and refractory disease. Tofacitinib, with the lowest total cost, was dominant in TNFi-failure scenarios. Golimumab offered the best value in dactylitis and comorbid patients and showed marked improvement under reduced-price conditions. Safety-related discontinuations were infrequent across cohorts. Ixekizumab, tofacitinib, and golimumab are all cost-effective options for PsA. These findings support phenotype-guided therapeutic decisions and highlight the influence of drug pricing.