Starting belimumab earlier in the treatment pathway for systemic lupus erythematosus (SLE) could improve quality-adjusted survival while reducing long-term healthcare costs compared with delayed initiation, according to recent research.
To examine the potential impact of treatment timing, a recent economic evaluation published in JAMA Network Open compared early versus delayed belimumab initiation in biologic-naive adults with clinically active SLE using a cost-utility analysis from a US healthcare payer perspective.
The international research team used a Markov state-transition model to simulate disease progression over a 15-year period in monthly cycles, with evidence informing the model gathered through a targeted literature review of studies published between 2013 and 2025.
The simulated cohort comprised 1,000 adults with active SLE, defined by a Systemic Lupus Erythematosus Disease Activity Index 2000 score greater than 0, and no prior biologic therapy. The modelled population was predominantly female (912 patients, 91.2%) with a mean age of 41 years at treatment initiation.
Two treatment strategies were compared: early initiation of intravenous belimumab within two years of disease diagnosis and delayed initiation after failure of standard immunosuppressive therapy.
Patients transitioned monthly among six health states: pre-treatment, complete response, partial response, non-response, no treatment and death, based on validated clinical measures including the SLE Responder Index-4.
Outcomes and costs with early belimumab initiation
Over the 15-year time horizon, early belimumab initiation was associated with both higher health benefits and lower overall costs than delayed belimumab treatment.
Early initiation resulted in 7.68 quality-adjusted life-years (QALYs) compared with 7.38 QALYs for delayed treatment, a gain of 0.30 QALYs (95% uncertainty interval [UI] −0.42 to 1.39). Early therapy also reduced mean total direct medical costs by $126,337.12 per patient (95% UI −$910,010.39 to $168,383.94).
This combination of greater effectiveness and lower costs produced an incremental cost-effectiveness ratio of −$421,123.73 per QALY, indicating that early belimumab was the dominant strategy compared with delayed initiation.
Probabilistic sensitivity analysis based on 10,000 simulations found that early treatment was preferred in 81.3% of simulations at a willingness-to-pay threshold of $50,000 per QALY, with a mean incremental net monetary benefit of $141,337.12.
Differences in economic outcomes were mainly influenced by the distribution of health states. Earlier belimumab treatment increased the number of patients reaching complete or partial response states – linked to higher health utility and lower healthcare costs – while delayed treatment resulted in more patients remaining in the costly non-responder state.
Limitations and SLE clinical implications
The authors cautioned that several limitations should be considered when interpreting the findings. Key model inputs were drawn from multinational studies rather than from exclusively US cohorts, meaning the analysis assumed broadly similar belimumab effects, health utilities and mortality risks across healthcare settings.
They also noted that the Markov modelling framework relies on fixed transition probabilities and may not fully capture the heterogeneous and fluctuating course of SLE.
Further limitations included the uniform application of cost and utility values across treatment groups, which may not reflect differences in real-world clinical management.
In addition, data on concomitant therapies such as hydroxychloroquine were unavailable, despite evidence that such treatments can influence clinical response and healthcare utilisation.
Nevertheless, the findings suggest that starting belimumab earlier in biologic-naive patients with active SLE could improve health outcomes and reduce long-term healthcare costs, supporting the reconsideration of current reimbursement policies that favour delaying biologics.
However, the authors noted that further research is needed to examine the timing of other targeted therapies in SLE and to determine whether early intervention may provide similar long-term clinical and economic benefits across different patient groups.
Reference
Hundal S et al. Cost-Effectiveness of Early vs Delayed Belimumab Treatment for Systemic Lupus Erythematosus. JAMA Netw Open 2026;9(2):e2560167.