Cost effectiveness of prostacyclins in pulmonary arterial hypertension

• Published in: Applied health economics and health policy 2012-05, Vol.10 (3), p.175-188
• Main Authors: Roman, Antonio, Barberà, Joan A., Escribano, Pilar, Sala, Maria L., Febrer, Laia, Oyagüez, Itziar, Sabater, Eliazar, Casado, Miguel Á.
• Format: Article
• Language: English
• Subjects: Antihypertensive Agents - administration & dosage; Antihypertensive Agents - economics; Antihypertensive Agents - pharmacology; Clinical trials; Computer Simulation; Cost analysis; Cost-Benefit Analysis; Cost-effectiveness; Cost-utility; Decision making; Discount rates; Drug therapy; Epoprostenol; Epoprostenol - analogs & derivatives; Epoprostenol - economics; Epoprostenol - therapeutic use; Health Administration; Health Economics; Humans; Hypertension; Hypertension, Pulmonary - drug therapy; Hypertension, Pulmonary - economics; Iloprost; Iloprost - economics; Iloprost - therapeutic use; Markov Chains; Medicine & Public Health; Meta-analysis; Models, Economic; Mortality; Original Research Article; Pathogenesis; Patients; Pharmacoeconomics and Health Outcomes; Prostaglandins I - economics; Prostaglandins I - therapeutic use; Public Health; Pulmonary arteries; Pulmonary hypertension; Quality of Life Research; Quality-Adjusted Life Years; Sensitivity analysis; Spain; Treprostinil.; Vasodilator Agents - economics; Vasodilator Agents - therapeutic use
• ISSN: 1175-5652; 1179-1896
• DOI: 10.2165/11630780-000000000-00000

Background Pulmonary arterial hypertension (PAH) is considered an orphan disease. Prostacyclins are the keystone for PAH treatment. Choosing between the three available prostacyclin therapies could be complicated because there are no comparison studies, so the final decision must be driven by factors such as efficacy, administration route, safety profile and economic aspects. Objective This study provides a cost-effectiveness and cost-utility comparison of initiating prostacyclin therapy with three different treatment alternatives (inhaled iloprost [ILO], intravenous epoprostenol [EPO] and subcutaneous treprostinil [TRE]) for patients with PAH. The goal of this work is to help physicians with their therapeutic decision-making. Methods A Markov model was built to simulate a patient cohort with class III PAH according to the classification of the New York Heart Association (NYHA). Four health states corresponding with the NYHA classes plus death were allowed for patients in the model. Changing the treatment was possible when patients worsened from functional class III to IV. The time horizon was 3 years, allowing patients to transition between health states on a 12-week cycle basis. The study perspective was that of the National Health System (NHS) [only direct medical costs were included]. Unitary costs were obtained from the Drug Catalogue and e-Salud Database in 2009 and are given in euros (€). Data on health resources and treatment pathways were informed by a four-member expert panel. Efficacy was obtained from pivotal clinical trials of ILO, EPO and TRE, the latter used in Spain as a foreign medication. Utilities for each health state were obtained from the literature. The final efficacy measure was life-years gained (LYG), and utilities were used to obtain quality-adjusted life-years (QALYs). Costs and effects were discounted at a 3% rate. To check for the robustness of the results, sensitivity analyses were performed. Results At the end of the 3 years, in the base case of the deterministic analysis, initiating prostacyclin therapy with iloprost was the less costly strategy (€132840), followed by treprostinil (€359 869) and epoprostenol (€429 775). Epoprostenol has shown the best efficacy results with 2.73 LYG and 1.78 QALY, followed by iloprost (2.69 LYG and 1.74 QALY) and treprostinil (2.69 LYG and 1.73 QALY). Incremental cost-effectiveness ratios (ICER) and cost-utility ratios (ICUR) of epoprostenol versus iloprost and treprostinil were much above t