Cost-effectiveness of disease-modifying treatments for multiple sclerosis in Bulgaria based on evidence from real world settings

Background: This study aims to provide insight on the early application of high efficacy 2 nd line DMDs from Bulgarian public payer perspective, referring to RWD. Methods: : An Excel-based model was developed to compare the effectiveness of 1 st vs 2 nd line DMDs in terms of ARRs and the direct medical costs over the 4-year follow up period. MS therapies were categorized in two groups (1 st and 2 nd line) according to public payer guidelines. The results of the cost-effectiveness analysis are presented as an ICER. Results: : The ARR of 0,385 for 1 st line DMDs was significantly higher than the one for 2 nd line DMDs, which was 0,153. The direct medical costs were 18 548 BGN and 33 857 BGN for 1 st and 2 nd line DMDs respectively. Thus, the incremental cost-effectiveness ratio (ICER) was 63 950 BGN per relapse avoided, which is slightly above the informal threshold of 3 x GDP per capital. Conclusion: The results of this study showed that escalation to 2 nd line DMDs is a cost-effective approach in RRMS patients who do not respond adequately to conventional 1 st line DMDs. Although 2 nd line DMDs direct medical costs were substantially higher, early escalation might produce long-term savings.