RESUMO
OBJECTIVE: To compare the relative healthcare costs, from the perspective of the Spanish National Healthcare System (NHS), of initiating treatment with either pregabalin, or SSRI/SNRI, as add-on therapies, in patients with generalized anxiety disorder (GAD), who are resistant to benzodiazepine-based therapy (BR). METHODS: BR out-patients with GAD (DSM-IV) who were included in a 6-month, prospective, multicentre, observational cohort study were selected for this post-hoc economic analysis. BR was defined as insufficient response, with persistence of symptoms of anxiety (HAM-Anxiety scale≥16), after a 6-month course of benzodiazepines. Patients had not been previously exposed to pregabalin or SSRI/SNRI. Healthcare resource utilization (drugs, medical visits, hospitalizations, etc.) associated with GAD was collected at baseline and end-of-trial visits. Related costs were estimated at each visit and adjusted changes were compared using ANCOVA. RESULTS: A total of 128 patients with refractory GAD were treated with pregabalin and 126 SSRI/SNRI. Compared with SSRI/SNRI, pregabalin was associated with significantly lower percentage of benzodiazepines users; 57.0% vs 87.3%, p<0.001, and greater reduction in medical visits; -15.1 vs -13.0, p=0.029. Mean total healthcare resource utilization costs decreased significantly in the pregabalin cohort only; -289 (p=0.003), although six months costs were not significantly different in both groups; 977 vs 822, respectively. CONCLUSION: Initiating treatment with pregabalin was associated with significant reduction in medical visits and total health care resource costs of GAD compared to SSRI/ SNRI in BR patients in the Spanish NHS setting. Compared with SSRI/SNRI, pregabalin therapy was accompanied by significantly less percentage of patients on concomitant benzodiazepines therapy.
Assuntos
Inibidores da Captação Adrenérgica/economia , Inibidores da Captação Adrenérgica/uso terapêutico , Transtornos de Ansiedade/tratamento farmacológico , Transtornos de Ansiedade/economia , Custos de Cuidados de Saúde , Inibidores Seletivos de Recaptação de Serotonina/economia , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Ácido gama-Aminobutírico/análogos & derivados , Adulto , Benzodiazepinas/uso terapêutico , Resistência a Medicamentos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pregabalina , Estudos Prospectivos , Espanha , Ácido gama-Aminobutírico/economia , Ácido gama-Aminobutírico/uso terapêuticoRESUMO
OBJECTIVE: To evaluate the safety and effectiveness of tetrabenazine for the treatment of tardive dyskinesia. DATA SOURCES: Literature was accessed through MEDLINE (1966-September 2010) and The Cochrane Library using the terms tetrabenazine, tardive dyskinesia, and movement disorders. In addition, references from publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION: All English-language articles identified from the data sources were reviewed. DATA SYNTHESIS: Options available for the management of tardive dyskinesia are limited. Tetrabenazine is a central monoamine-depleting agent approved by the Food and Drug Administration for chorea associated with Huntington's disease. Three prospective studies of tetrabenazine in the treatment of tardive dyskinesia were identified, as well as 8 additional trials, 1 case series, and 8 case reports. Tetrabenazine may provide benefit in managing symptoms of tardive dyskinesia unresponsive to other treatment modalities. Treatment of tardive dyskinesia with tetrabenazine may be limited by cost and clinically significant adverse effects such as depression, parkinsonism, and somnolence. CONCLUSIONS: Small trials indicate tetrabenazine may be effective for the treatment of tardive dyskinesia. However, larger, well-conducted trials are needed to confirm these findings. Currently, there is a lack of data coupled with the risk of significant adverse effects to recommend the routine use of tetrabenazine in the management of tardive dyskinesia. Before using tetrabenazine for the management of tardive dyskinesia, all other options should be exhausted and careful monitoring employed.
Assuntos
Inibidores da Captação Adrenérgica/uso terapêutico , Transtornos dos Movimentos/tratamento farmacológico , Tetrabenazina/uso terapêutico , Inibidores da Captação Adrenérgica/efeitos adversos , Inibidores da Captação Adrenérgica/economia , Ensaios Clínicos como Assunto , Humanos , Estudos Prospectivos , Tetrabenazina/efeitos adversos , Tetrabenazina/economiaRESUMO
INTRODUCTION AND HYPOTHESIS: In order to better understand provider treatment patterns for interstitial cystitis (IC)/painful bladder syndrome, we sought to document the therapies utilized and their associated expenditures using a national dataset. METHODS: A cohort was created by applying the ICD-9 diagnosis of IC (595.1) to INGENIX claims for the year 1999. Subjects were followed for 5 years, and patterns of care and related expenditures were evaluated. RESULTS: Of 553,910 adults insured in 1999, 89 subjects had a diagnosis of IC with 5-year follow-up data. All subjects were treated with oral medication(s), 26% received intravesical treatments, and 22% underwent hydrodistension. Total expenditures per subject were $2,808. CONCLUSIONS: The majority of IC expenditures were attributable to oral medical therapy. Hydrodistension and intravesical instillations were utilized in less than 25% of patients. Hydrodistension was used more frequently among subjects with a new diagnosis; this may reflect its utilization as part of a diagnostic algorithm.
Assuntos
Cistite Intersticial/tratamento farmacológico , Antagonistas Muscarínicos/uso terapêutico , Entorpecentes/uso terapêutico , Administração Intravesical , Administração Oral , Inibidores da Captação Adrenérgica/economia , Inibidores da Captação Adrenérgica/uso terapêutico , Adulto , Idoso , Aminas/economia , Aminas/uso terapêutico , Amitriptilina/economia , Amitriptilina/uso terapêutico , Anticoagulantes/economia , Anticoagulantes/uso terapêutico , Ácidos Cicloexanocarboxílicos/economia , Ácidos Cicloexanocarboxílicos/uso terapêutico , Cistite Intersticial/economia , Feminino , Gabapentina , Humanos , Pessoa de Meia-Idade , Antagonistas Muscarínicos/economia , Entorpecentes/economia , Poliéster Sulfúrico de Pentosana/economia , Poliéster Sulfúrico de Pentosana/uso terapêutico , Padrões de Prática Médica , Resultado do Tratamento , Adulto Jovem , Ácido gama-Aminobutírico/economia , Ácido gama-Aminobutírico/uso terapêuticoRESUMO
OBJECTIVE: To assess the cost-effectiveness of duloxetine compared with conservative therapy in women with stress urinary incontinence (SUI). METHODS: Cost and outcome data were taken from the Stress Urinary Incontinence Treatment (SUIT) study, a 12-month, prospective, observational, naturalistic, multicenter, multicountry study. Costs were assessed in UK pound and outcomes in quality adjusted life years using responses to the EuroQol (EQ-5D); numbers of urine leaks were also estimated. Potential selection bias was countered using multivariate regression and propensity score analysis. RESULTS: Duloxetine alone, duloxetine in combination with conservative treatment, and conservative treatment alone were associated with roughly two fewer leaks per week compared with no treatment. Duloxetine alone and with conservative treatment for SUI were associated with incremental quality-adjusted life-years (QALYs) of about 0.03 over a year compared with no treatment or with conservative treatment alone. Conservative treatment alone did not show an effect on QALYs. None of the interventions appeared to have marked impacts on costs over a year. Depending on the form of matching, duloxetine either dominated or had an incremental cost-effectiveness ratio (ICER) below pound900 per QALY gained compared with no treatment and with conservative treatment alone. Duloxetine plus conservative therapy had an ICER below pound5500 compared with no treatment or conservative treatment alone. Duloxetine compared with duloxetine plus conservative therapy showed similar outcomes but an additional cost for the combined intervention. CONCLUSIONS: Although the limitations of the use of SUIT's observational data for this purpose need to be acknowledged, the study suggests that initiating duloxetine therapy in SUI is a cost-effective treatment alternative.
Assuntos
Inibidores da Captação Adrenérgica/economia , Tiofenos/economia , Incontinência Urinária por Estresse/tratamento farmacológico , Incontinência Urinária por Estresse/economia , Inibidores da Captação Adrenérgica/uso terapêutico , Estudos de Coortes , Análise Custo-Benefício , Cloridrato de Duloxetina , Feminino , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Indicadores Básicos de Saúde , Humanos , Internacionalidade , Pessoa de Meia-Idade , Análise Multivariada , Avaliação de Resultados em Cuidados de Saúde , Pontuação de Propensão , Estudos Prospectivos , Qualidade de Vida/psicologia , Anos de Vida Ajustados por Qualidade de Vida , Análise de Regressão , Tiofenos/uso terapêutico , Reino Unido , Incontinência Urinária por Estresse/psicologia , Saúde da MulherRESUMO
BACKGROUND: Attention Deficit/Hyperactivity Disorder (ADHD) is a neurobehavioural disorder, affecting 3-6% of school age children and adolescents in Spain. Methylphenidate (MPH), a mild stimulant, had long been the only approved medication available for ADHD children in Spain. Atomoxetine is a non-stimulant alternative in the treatment of ADHD with once-a-day oral dosing. This study aims to estimate the cost-effectiveness of atomoxetine compared to MPH. In addition, atomoxetine is compared to 'no medication' for patient populations who are ineligible for MPH (i.e. having stimulant-failure experience or co-morbidities precluding stimulant medication). METHODS: An economic model with Markov processes was developed to estimate the costs and benefits of atomoxetine versus either MPH or 'no medication'. The incremental cost per quality-adjusted life-year (QALY) was calculated for atomoxetine relative to the comparators. The Markov process incorporated 14 health states, representing a range of outcomes associated with treatment options. Utility values were obtained from the utility valuation survey of 83 parents of children with ADHD. The clinical data were based on a thorough review of controlled clinical trials and other clinical literature, and validated by international experts. Costs and outcomes were estimated using Monte Carlo simulation over a 1-year duration, with costs estimated from the perspective of the National Health Service in Spain. RESULTS: For stimulant-naive patients without contra-indications to stimulants, the incremental costs per QALY gained for atomoxetine were euro 34,308 (compared to an immediate-release MPH) and euro 24,310 (compared to an extended-release MPH). For those patients who have stimulant-failure experience or contra-indications to stimulants, the incremental costs per QALY gained of atomoxetine compared to 'no medication' were euro 23,820 and euro 23,323, respectively. CONCLUSION: The economic evaluation showed that atomoxetine is an effective alternative across a range of ADHD populations and offers value-for money in the treatment of ADHD.
Assuntos
Inibidores da Captação Adrenérgica/economia , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Estimulantes do Sistema Nervoso Central/economia , Metilfenidato/economia , Modelos Econômicos , Propilaminas/economia , Adolescente , Inibidores da Captação Adrenérgica/uso terapêutico , Cloridrato de Atomoxetina , Estimulantes do Sistema Nervoso Central/uso terapêutico , Criança , Ensaios Clínicos Controlados como Assunto , Análise Custo-Benefício , Humanos , Cadeias de Markov , Metilfenidato/uso terapêutico , Propilaminas/uso terapêutico , EspanhaRESUMO
BACKGROUND: Economic evaluation of healthcare technologies is becoming increasingly relevant, enabling decision makers to assess and compare treatments within the context of costs and outcomes. Moreover, it is increasingly important for clinicians and prescribers to have some understanding of economic evaluation. For attention-deficit/hyperactivity disorder (ADHD), economic evaluations have largely focused on pharmacotherapy, and results indicate that such treatments are cost-effective compared with other interventions. AIMS: This review provides an overview of ADHD, its consequences and pharmacotherapy; describes the principles of health economic analysis, health-related quality of life (HRQL) and a cost-effectiveness model of atomoxetine for ADHD treatment; and outlines guidance from the National Institute for Health and Clinical Excellence on ADHD pharmacotherapy. METHODS: The cost-effectiveness of atomoxetine for children with ADHD in the UK was compared with treatment alternatives using an economic model with Markov processes. The model evaluated atomoxetine in five patient subgroups according to treatment history and comorbidities precluding stimulants. Incremental cost per quality-adjusted life-year (QALY) was calculated and compared between treatment algorithms. The Markov process incorporated 18 health states, representing a range of outcomes across the treatments. Utility values were derived from a survey of 83 parents of children with ADHD, and treatment efficacy and safety were based on a review of controlled clinical trials and literature, and validated by international experts. Costs and outcomes were estimated using Monte Carlo simulation over 1-year. RESULTS: Atomoxetine was a cost-effective treatment across the whole ADHD population, with incremental cost-effectiveness ratios ranging from pound 11,500 to pound 15,900 per QALY, compared with alternative pharmacotherapies, which are within UK and rest of Europe acceptability limits. Higher utility values achieved treating ADHD with atomoxetine, compensate for the relatively higher acquisition cost compared with stimulants. CONCLUSIONS: Atomoxetine is cost-effective and may have advantages over stimulants, including benefits to HRQL and no abuse liability and is the only treatment in the UK licensed for continued treatment into adulthood in adolescents who have shown a response from treatment.
Assuntos
Inibidores da Captação Adrenérgica/uso terapêutico , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Propilaminas/uso terapêutico , Adolescente , Inibidores da Captação Adrenérgica/economia , Cloridrato de Atomoxetina , Transtorno do Deficit de Atenção com Hiperatividade/economia , Criança , Análise Custo-Benefício , Humanos , Guias de Prática Clínica como Assunto , Propilaminas/economia , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Reino UnidoRESUMO
Introduction: The prevalence of Attention-Deficit/Hyperactivity Disorder (ADHD) has risen over the last two decades, with a corresponding increase in the cost of its medication. Drug utilization studies in South Africa focusing on ADHD are limited.Areas covered: The primary aim was to determine the cost of methylphenidate and atomoxetine (used for ADHD). The Intercontinental Marketing Service (IMS) database which contains data of the private healthcare sector was interrogated from 2013 to 2016 (48-month period) focussing on methylphenidate and atomoxetine. Drug consumption was expressed in number of DDDs, DDDs/1000 inhabitants/day and cost in Rands.Expert opinion: Methylphenidate-containing products constituted a considerably higher percentage of the market share when compared to atomoxetine (90.30% versus 9.70%). The DDD/1000 inhabitants/day for methylphenidate was 6.010 with an annual cost for R266 691 778 in 2013, which increased to 7.827 DDDs/1000 inhabitants/day with an annual cost of R436 041 506 in 2016. Consumption of both methylphenidate and atomoxetine increased from 2013 to 2016. There was a preference for long-acting extended-release methylphenidate tablets even though the unit costs were higher when compared to the short-acting formulations. Despite increases in unit costs, the spend in South Africa showed an upward trend for methylphenidate and atomoxetine.
Assuntos
Cloridrato de Atomoxetina/administração & dosagem , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Metilfenidato/administração & dosagem , Inibidores da Captação Adrenérgica/administração & dosagem , Inibidores da Captação Adrenérgica/economia , Cloridrato de Atomoxetina/economia , Transtorno do Deficit de Atenção com Hiperatividade/economia , Estimulantes do Sistema Nervoso Central/administração & dosagem , Estimulantes do Sistema Nervoso Central/economia , Humanos , Metilfenidato/economia , Setor Privado/economia , África do SulRESUMO
OBJECTIVE: To estimate the cost-effectiveness of atomoxetine for children with attention-deficity/hyperactivity disorder (ADHD) in the United Kingdom compared with current alternatives. METHODS: An economic model with Markov processes was developed to estimate the costs and benefits of atomoxetine versus other current ADHD treatment options. The model evaluated atomoxetine in five patient subgroups according to treatment history and the existence of comorbidities precluding stimulant medication. The incremental cost per quality-adjusted life-year (QALY) was calculated for atomoxetine treatment algorithms compared with comparator algorithms. The Markov process incorporated 18 health states, representing a range of outcomes across all treatment options included in the algorithms. Utility values were derived from a survey of 83 parents of children with ADHD. The effectiveness and safety aspects of the treatment options were based on a thorough review of controlled clinical trials and other clinical literature, and validated by international experts. Costs and outcomes were estimated using Monte Carlo simulation over a 1-year duration, with costs estimated from the perspective of the National Health Service in England and Wales. RESULTS: For stimulant-naive patients, the incremental cost per QALY gained for the atomoxetine algorithm compared with immediate-release methylphenidate hydrochloride (MPH) was pound 15,224 ( pound 13,241 compared with extended-release MPH). In the stimulant-exposed populations, the incremental cost per QALY for the atomoxetine algorithm was between pound 14,169 and pound 15,878. For patients contraindicated for stimulant therapies, the incremental cost per QALY was pound 11,523 and pound 12,370 for stimulant-naive and stimulant-exposed populations, respectively. CONCLUSION: The economic evaluation showed atomoxetine is an effective alternative across a range of ADHD populations and offers value-for-money in the treatment of ADHD.
Assuntos
Inibidores da Captação Adrenérgica/economia , Inibidores da Captação Adrenérgica/uso terapêutico , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Transtorno do Deficit de Atenção com Hiperatividade/economia , Estimulantes do Sistema Nervoso Central/economia , Estimulantes do Sistema Nervoso Central/uso terapêutico , Metilfenidato/economia , Metilfenidato/uso terapêutico , Modelos Econômicos , Propilaminas/economia , Propilaminas/uso terapêutico , Algoritmos , Cloridrato de Atomoxetina , Criança , Análise Custo-Benefício , Humanos , Cadeias de Markov , Método de Monte Carlo , Anos de Vida Ajustados por Qualidade de Vida , Reino UnidoRESUMO
OBJECTIVE: To determine the cost effectiveness, from the Brazilian Ministry of Health viewpoint, of three antidepressant classes for major depressive disorder (MDD), and the budget impact of introducing serotonin-noradrenaline (norepinephrine) reuptake inhibitors (SNRIs) into the current Brazilian national drug formulary, assuming a 6-month treatment duration. METHODS: An existing decision-tree model was adapted to Brazil, based on local guidelines. Clinical data were obtained from published meta-analyses. Patients included adults aged > or =18 years with MDD, diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, third and fourth editions (DSM-III/IV), with moderate-to-severe disease (Hamilton Depression Rating Scale [HAMD] > or =15 or Montgomery-Asberg Depression Rating Scale [MADRS] > or =18), without co-morbidities or co-medications, receiving > or =6 weeks of treatment with SNRIs, selective serotonin reuptake inhibitors (SSRIs) and/or tricyclic antidepressants (TCAs). Clinical outcome was remission (HAMD < or =7 or MADRS < or =12). Direct costs (drugs, physician visits, hospitalisations) were included. Drug costs were obtained from the 2006 Brazilian National Drug Price List, and hospitalisation and physician costs from the 2006 Healthcare System database. Costs were valued in Brazilian Reais ($Brz), year 2006 values ($Brz1 = $US0.47). Univariate and Monte Carlo sensitivity analyses tested model robustness. RESULTS: Expected costs per patient treated were SNRIs $Brz4848; SSRIs $Brz5466; and TCAs $Brz5046, and overall success rates (primary plus secondary treatment across all decision tree branches) were SNRIs 78.1%; SSRIs 74.0%; and TCAs 76.4%. Average costs/success were SNRIs $Brz6209; SSRIs $Brz7385; and TCAs $Brz6602. SNRIs dominated in incremental cost-effectiveness analyses. Monte Carlo analysis confirmed drug classes' relative positions; however, there was considerable uncertainty. Introducing SNRIs into the formulary could generate average savings of 1% of the total budget, with a 52% probability of savings. CONCLUSIONS: SNRIs appear to be cost effective against SSRIs and TCAs when prescribed to patients with MDD in Brazil. However, their inclusion into the national drug list would generate minor savings compared with the current formulary of SSRIs and TCAs. Thus, we considered such inclusion as 'cost-neutral', since no major probability of savings or increased expenditures were observed.
Assuntos
Inibidores da Captação Adrenérgica/economia , Inibidores da Captação Adrenérgica/uso terapêutico , Transtorno Depressivo/economia , Transtorno Depressivo/epidemiologia , Inibidores Seletivos de Recaptação de Serotonina/economia , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Brasil/epidemiologia , Orçamentos , Análise Custo-Benefício , Transtorno Depressivo/tratamento farmacológico , Formulários Farmacêuticos como Assunto , Humanos , Escalas de Graduação PsiquiátricaRESUMO
BACKGROUND: Many therapies exist for treating adult attention-deficit/hyperactivity disorder (ADHD), also referred to as attention-deficit disorder (ADD), but there is no research regarding cost differences associated with initiating alternative ADD/ADHD drug therapies in adults. OBJECTIVE: To compare from the perspective of a large self-insured employer the risk-adjusted direct health care costs associated with 3 alternative drug therapies for ADD in newly treated patients: extended-release methylphenidate (osmotic release oral system-MPH), mixed amphetamine salts extended release (MAS-XR), or atomoxetine. METHODS: We analyzed data from a US claims database of 5 million beneficiaries from 31 large self-insured employers (1999-2004). Analysis was restricted to adults aged 18 to 64 years with at least 1 diagnosis of ADD/ADHD (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 314.0x--attention deficit disorder; 314.00--attention deficit disorder without hyperactivity; or 314.01--attention-deficit disorder with hyperactivity) and at least 1 pharmacy claim for OROS-MPH, MAS-XR, or atomoxetine identified using National Drug Codes. In preliminary analysis, we calculated the duration of index ADHD drug therapy as time from index therapy initiation to a minimum 60-day gap. Because the median duration of index ADHD drug therapy was found to be approximately 90 days, the primary measures were total direct medical plus drug costs and medical-only costs computed over 6 months following therapy initiation. Adults were required to have continuous eligibility 6 months before and 6 months after their latest drug therapy initiation and no ADHD therapy during the previous 6 months. Cost was measured as the payment amount made by the health plan to the provider rather than billed charges, and it excluded patient copayments and deductibles. Medical costs included costs incurred for all-cause inpatient and outpatient/other services. Costs were adjusted for inflation to 2004 U.S. dollars using the consumer price index for medical care. T tests were used for descriptive cost comparisons. Generalized linear models (GLMs) were used to compare costs of adults receiving alternative therapies, adjusting for demographic characteristics, substance abuse, depression, and the Charlson Comorbidity Index. RESULTS: Of the 4,569 patients who received 1 of these 3 drug therapies for ADHD, 31.8% received OROS-MPH for a median duration of 99 days of therapy, 34.0% received MAS-XR for a median 128 days, and 34.2% received atomoxetine for a median 86 days. In the 6-month follow-up period, the mean (standard deviation) total medical and drug costs were $2,008 ($3,231) for OROS-MPH, $2,169 ($4,828) for MAS-XR, and $2,540 ($4,269) for atomoxetine-treated adults. The GLM for patient characteristics suggested that 6-month, risk-adjusted mean medical costs, excluding drug costs, for adults treated with OROS-MPH were $142 less (10.4%, $1,220 vs. $1,362) compared with MAS-XR (P =0.022) and $132 less (9.8%, $1,220 vs. $1,352) compared with atomoxetine (P =0.033); risk-adjusted mean medical costs were not significantly different between MAS-XR and atomoxetine. The GLM comparison of risk-adjusted total direct costs, including drug cost, was on average $156 less (8.0%, $1,782 vs. $1,938) for OROS-MPH compared with MAS-XR (P = 0.017) and $226 less (11.3%, $1,782 vs. $2,008) compared with atomoxetine (P <0.001); the risk-adjusted total direct costs were not significantly different between MAS-XR and atomoxetine. Two high-cost outliers (greater than 99.96th percentile, 1 each for OROS-MPH and atomoxetine) accounted for $47 (30%) of the $156 cost difference between OROS-MPH and MAS-XR and $11 (5%) of the $226 cost difference between OROS-MPH and atomoxetine, and the medical diagnoses for the highest-cost claims for these 2 outlier patients were unrelated to ADHD. CONCLUSIONS: After adjusting for patient characteristics including substance abuse, depression, and the Charlson Comorbidity Index, adults treated with OROS-MPH had, on average, slightly lower medical and total medical and drug costs than those treated with MAS-XR or atomoxetine over the 6-month period after drug therapy initiation. Approximately 30% of the cost difference compared with MAS-XR was attributable to 1 high-cost outlier with medical diagnoses for the highest-cost claim that were unrelated to ADHD.
Assuntos
Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Transtorno do Deficit de Atenção com Hiperatividade/economia , Custos de Cuidados de Saúde , Inibidores da Captação Adrenérgica/economia , Inibidores da Captação Adrenérgica/uso terapêutico , Adulto , Anfetaminas/economia , Anfetaminas/uso terapêutico , Cloridrato de Atomoxetina , Estimulantes do Sistema Nervoso Central/economia , Estimulantes do Sistema Nervoso Central/uso terapêutico , Custos e Análise de Custo/métodos , Bases de Dados Factuais/estatística & dados numéricos , Preparações de Ação Retardada/economia , Preparações de Ação Retardada/uso terapêutico , Feminino , Humanos , Seguro Saúde/estatística & dados numéricos , Seguro de Serviços Farmacêuticos/economia , Seguro de Serviços Farmacêuticos/estatística & dados numéricos , Masculino , Programas de Assistência Gerenciada/economia , Programas de Assistência Gerenciada/estatística & dados numéricos , Metilfenidato/economia , Metilfenidato/uso terapêutico , Pessoa de Meia-Idade , Análise Multivariada , Propilaminas/economia , Propilaminas/uso terapêutico , Reprodutibilidade dos Testes , Fatores de TempoRESUMO
In 2001, we concluded that methylphenidate or dexamfetamine can be useful adjunctive therapy for children with severe hyperactivity in whom non-drug approaches alone have been inadequate. Since then, atomoxetine (pronounced a-toe-moks-e-teen; Strattera - Lilly) and three modified-release formulations of methylphenidate have been launched for attention deficit hyperactivity disorder (ADHD). Here we reconsider drugs for ADHD in childhood, focusing on the newer products.
Assuntos
Inibidores da Captação Adrenérgica/uso terapêutico , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Estimulantes do Sistema Nervoso Central/uso terapêutico , Inibidores da Captação Adrenérgica/economia , Cloridrato de Atomoxetina , Transtorno do Deficit de Atenção com Hiperatividade/economia , Estimulantes do Sistema Nervoso Central/economia , Criança , Preparações de Ação Retardada , Dextroanfetamina/economia , Dextroanfetamina/uso terapêutico , Custos de Medicamentos , Humanos , Metilfenidato/economia , Metilfenidato/uso terapêutico , Propilaminas/economia , Propilaminas/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) imposes a substantial burden on patients and their families. OBJECTIVE: A retrospective, propensity score-matched cohort study compared treatment patterns, healthcare resource utilization (HRU) and costs among children/adolescents with ADHD aged 6-17 years at treatment initiation (index) in Germany who received atomoxetine (ATX) or long-acting methylphenidate (LA-MPH) monotherapy. METHODS: Patients received at least one prescription for their index medication (ATX/LA-MPH) during 2006-2010; the first prescription marked the index date. ATX- and LA-MPH-indexed cohorts were matched 1:1 (n = 737); a patient subset was identified that had not received ADHD-indicated medications in 12 months prior to index (novel initiators: ATX, n = 486; LA-MPH, n = 488). Treatment patterns were evaluated among novel initiators, and HRU and costs among the matched cohorts in the 12 months after index. RESULTS: No significant differences in baseline characteristics were found between the novel initiator patient subsets. ATX-indexed novel initiators had significantly longer persistence to index medication [mean (standard deviation; SD) days: 222.0 (133.9) vs 203.2 (135.0), P = 0.029) but higher switching rates (8.8 vs 5.5 %, P = 0.045) than LA-MPH-indexed novel initiators. The total ATX-indexed cohort required more prescriptions [any medication; mean (SD): 20.9 (11.5) vs 15.7 (9.0), P < 0.001] and outpatient visits [mean (SD): 10.1 (6.3) vs 8.3 (5.3), P < 0.001], and incurred significantly higher total median healthcare costs (1144 vs 541, P < 0.001) versus matched LA-MPH patients. CONCLUSIONS: These real-world data indicate that, among children/adolescents with ADHD in Germany, ATX-indexed patients may require more prescriptions and physician visits, and incur higher total healthcare costs, than matched LA-MPH patients.
Assuntos
Inibidores da Captação Adrenérgica/uso terapêutico , Cloridrato de Atomoxetina/uso terapêutico , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Estimulantes do Sistema Nervoso Central/uso terapêutico , Recursos em Saúde/estatística & dados numéricos , Metilfenidato/uso terapêutico , Adolescente , Inibidores da Captação Adrenérgica/economia , Cloridrato de Atomoxetina/economia , Estimulantes do Sistema Nervoso Central/administração & dosagem , Estimulantes do Sistema Nervoso Central/economia , Criança , Preparações de Ação Retardada , Feminino , Alemanha , Humanos , Masculino , Metilfenidato/administração & dosagem , Metilfenidato/economia , Modelos Econométricos , Estudos RetrospectivosRESUMO
BACKGROUND: Duloxetine is a serotonin and norepinephrine reuptake inhibitor and may be useful for treating women with stress urinary incontinence (SUI) in general practice. OBJECTIVE: The objective of this study was to examine the cost-effectiveness of 2 duloxetine strategies (duloxetine alone and duloxetine after inadequate response to pelvic floor muscle training [PFMT]) compared with PFMT or no treatment for women aged>or=50 years with SUI. METHODS: A Markov model with a 3-month cycle length was developed, with a time horizon of 5 years. Incontinence severity was based on incontinence episode frequency per week (IEF/week). Four SUI health states were distinguished in the model: no SUI (0 incontinence episode [IE] per week), mild SUI (19 IEs/week), moderate SUI (10-25 IEs/week), and severe SUI (>or=26 IEs/week). Transition probabilities were calculated, based on published evidence, expert opinion, and demographic data. Outcomes were expected total societal costs and expected IEs. The analysis was performed from the societal perspective of The Netherlands, and all costs were reported in year-2002 euros. One-way sensitivity and probabilistic sensitivity analyses were performed. RESULTS: In the model, providing PFMT cost euro0.03/IE avoided, compared with no treatment. Duloxetine after inadequate PFMT cost euro3.81/IE avoided, compared with PFMT One-way sensitivity analyses indicated that these results were robust regarding variation in age, IEF/week, and discount rate. Below the ceiling ratio of euro3.65/IE avoided, PFMT had the highest probability of being cost-effective. With higher ceiling ratios, duloxetine after inadequate PFMT had the highest cost-effectiveness probability. CONCLUSIONS: Treating patients with duloxetine after inadequate PFMT response yielded additional health effects in the model, but would require society in The Netherlands to pay euro3.81/IE avoided for women aged>or=50 years with SUI being treated in general practice. It is up to policy-makers to determine whether this ratio would be acceptable.
Assuntos
Inibidores da Captação Adrenérgica/economia , Inibidores da Captação Adrenérgica/uso terapêutico , Terapia por Exercício/economia , Diafragma da Pelve/fisiologia , Tiofenos/economia , Tiofenos/uso terapêutico , Incontinência Urinária/economia , Incontinência Urinária/terapia , Inibidores da Captação Adrenérgica/efeitos adversos , Idoso , Análise Custo-Benefício , Método Duplo-Cego , Cloridrato de Duloxetina , Feminino , Humanos , Cadeias de Markov , Pessoa de Meia-Idade , Modelos Estatísticos , Pacientes Desistentes do Tratamento , Estudos Prospectivos , Tiofenos/efeitos adversos , Resultado do Tratamento , Incontinência Urinária/tratamento farmacológicoRESUMO
UNLABELLED: The purpose of this study was to compare the cost-effectiveness of duloxetine versus routine treatment in management of diabetic peripheral neuropathic pain (DPNP). Two hundred thirty-three patients with DPNP who completed a 12-week, double-blind, placebo-controlled, randomized, multicenter duloxetine trial were re-randomized into a 52-week, open-label trial of duloxetine 60 mg twice daily versus routine treatment. Routine treatment included pain management therapies. Effectiveness was measured by using the bodily pain domain (BP) of the Medical Outcomes Study Short Form 36 (SF-36). Costs were analyzed from 3 perspectives: third party payer (direct medical costs), employer (direct and indirect medical costs), and societal (patient's out-of-pocket costs and total medical costs). Costs of study medications were not included because of limited data. Bootstrap method was applied to calculate statistical inference of the incremental cost-effectiveness ratio (ICER). Routine treatment most frequently used included gabapentin (56%), venlafaxine (36%), and amitripytline (15%). From employer and societal perspectives, duloxetine was cost-effective (ICER= -342 dollars and -429 dollars, respectively, per unit of SF-36 BP; both P Assuntos
Analgesia/economia
, Analgesia/métodos
, Neuropatias Diabéticas/tratamento farmacológico
, Medição da Dor/efeitos dos fármacos
, Limiar da Dor/efeitos dos fármacos
, Tiofenos/administração & dosagem
, Inibidores da Captação Adrenérgica/administração & dosagem
, Inibidores da Captação Adrenérgica/economia
, Idoso
, Aminas/administração & dosagem
, Aminas/economia
, Amitriptilina/administração & dosagem
, Amitriptilina/economia
, Analgésicos/administração & dosagem
, Analgésicos/economia
, Encéfalo/efeitos dos fármacos
, Encéfalo/metabolismo
, Estudos de Coortes
, Análise Custo-Benefício
, Ácidos Cicloexanocarboxílicos/administração & dosagem
, Ácidos Cicloexanocarboxílicos/economia
, Cicloexanóis/administração & dosagem
, Cicloexanóis/economia
, Neuropatias Diabéticas/metabolismo
, Neuropatias Diabéticas/fisiopatologia
, Método Duplo-Cego
, Cloridrato de Duloxetina
, Feminino
, Gabapentina
, Humanos
, Masculino
, Pessoa de Meia-Idade
, Norepinefrina/metabolismo
, Efeito Placebo
, Serotonina/metabolismo
, Tiofenos/economia
, Resultado do Tratamento
, Estados Unidos
, Cloridrato de Venlafaxina
, Ácido gama-Aminobutírico/administração & dosagem
, Ácido gama-Aminobutírico/economia
RESUMO
BACKGROUND: Depression and headache are highly prevalent in clinical settings. The co-occurrence of headache may impact choice of antidepressants, healthcare utilisation, and outcomes in patients with depression. The current study aims to examine the cost-effectiveness and cost-utility of different antidepressants for treating patients with depression and comorbid headache disorders. METHODS: Adult patients prescribed with antidepressants for depression (n=96,501) were identified from the National Health Insurance Research Database in Taiwan. A cost-effectiveness and cost-utility analysis was conducted comparing selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs), and by the presence of comorbid headache disorders and other pain conditions. RESULTS: In this study, SSRIs dominated SNRIs in both cost-effectiveness and cost-utility. As revealed in the cost-effectiveness acceptability curves, TCAs were likely to have a cost-utility advantage compared to SSRIs and SNRIs in improving quality-adjusted life years (QALYs) for patients with comorbid headache; SSRIs remained as the most cost-effective option for patients with other pain conditions. LIMITATIONS: Limitations include the use of proxy definition of remission as effectiveness measure and the adoption of utility values from previous studies. CONCLUSIONS: Given a pre-determined willingness-to-pay level, TCAs can be considered as a cost-effective option to improve QALYs for depressed patients with headache disorders. Future research is needed to further clarify factors influencing the cost-effectiveness and cost-utility of pharmacological treatments in depressed patients with specific pain conditions.
Assuntos
Antidepressivos/economia , Antidepressivos/uso terapêutico , Transtorno Depressivo/complicações , Transtorno Depressivo/tratamento farmacológico , Transtornos da Cefaleia/complicações , Inibidores da Captação Adrenérgica/economia , Inibidores da Captação Adrenérgica/uso terapêutico , Adulto , Idoso , Antidepressivos Tricíclicos/economia , Antidepressivos Tricíclicos/uso terapêutico , Análise Custo-Benefício , Transtorno Depressivo/economia , Feminino , Transtornos da Cefaleia/economia , Humanos , Masculino , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida , Inibidores Seletivos de Recaptação de Serotonina/economia , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Taiwan/epidemiologia , Resultado do TratamentoAssuntos
Inibidores da Captação Adrenérgica/administração & dosagem , Doença de Huntington/tratamento farmacológico , Discinesia Tardia/tratamento farmacológico , Tetrabenazina/análogos & derivados , Proteínas Vesiculares de Transporte de Monoamina/antagonistas & inibidores , Inibidores da Captação Adrenérgica/efeitos adversos , Inibidores da Captação Adrenérgica/economia , Custos de Medicamentos , Interações Medicamentosas , Humanos , Doença de Huntington/diagnóstico , Doença de Huntington/fisiopatologia , Doença de Huntington/psicologia , Discinesia Tardia/diagnóstico , Discinesia Tardia/fisiopatologia , Discinesia Tardia/psicologia , Tetrabenazina/administração & dosagem , Tetrabenazina/efeitos adversos , Tetrabenazina/economia , Resultado do Tratamento , Proteínas Vesiculares de Transporte de Monoamina/metabolismoRESUMO
BACKGROUND: About 7% of children and adolescents are diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the US. Patients with ADHD who are intolerant of or do not have an optimal response to stimulants often use non-stimulants as alternative therapies. Guanfacine extended-release (GXR) and atomoxetine (ATX) are the only non-stimulants approved by the US Food and Drug Administration for once-daily use in the treatment of children and adolescents with ADHD in the US. ATX has been on the market since 2002 while GXR was recently approved in 2009. To date, there is no comparative effectiveness or cost-effectiveness study comparing the two drugs. OBJECTIVES: The aim of this study was to assess the cost effectiveness of GXR versus ATX for the treatment of ADHD in children and adolescents, using the comparative efficacy results from a matching-adjusted indirect comparison (MAIC). METHODS: The MAIC method was used to compare the efficacy between GXR (target dose and lower doses) and ATX (target dose) in the absence of head-to-head clinical trials. Individual patients in the GXR trials were weighted such that the summary baseline characteristics and the efficacy of the placebo arm of the GXR trials matched exactly with those from published ATX trials. After weighting, the efficacy (i.e. change in the ADHD rating scale, fourth edition [ADHD-RS-IV] total score from baseline) was compared between each GXR dosing group and the ATX group. The results from the MAIC analyses were used to populate a 1-year Markov model that is used to compare the cost effectiveness of GXR versus ATX from a US third-party payer perspective. Effectiveness outcomes for each treatment group were estimated as the proportion of responders, defined as patients with ≥25% reduction in ADHD-RS-IV total score from baseline, and average quality-adjusted life years (QALYs). Utilities associated with response/non-response and disutilities due to adverse events were applied in the model. Costs included drug and medical service costs and were inflated to 2011 US dollars ($US). Incremental cost/QALY and incremental cost/responder were estimated. Univariate sensitivity analyses were conducted by varying all model parameters, including costs, utilities, and response rate. RESULTS: The target dose of GXR was 0.12 mg/kg/day. In match-adjusted populations with balanced baseline characteristics, patients receiving GXR at the dose of 0.09-0.12(p = 0.0016) [DOSAGE ERROR CORRECTED] and 0.075-0.09 mg/kg/day (p = 0.0248) had better efficacy, while those receiving GXR at the dose of 0.046-0.075 mg/kg/day had comparable efficacy (p = 0.0699), compared with patients receiving ATX at the target dose of 1.2 mg/kg/day. In the base case of the cost-effectiveness analysis (CEA), GXR had incremental cost-effectiveness ratios of $US10 637/QALY and $US853/responder, compared with ATX (incremental costs: $US74; incremental effectiveness: 0.007 QALYs and 86 responders per 1000 patients treated). Results of all univariate sensitivity analyses showed that the model results were robust to changes in model inputs. CONCLUSIONS: To our knowledge, this is the first application of the novel comparative efficacy method of MAIC to a CEA model. The MAIC results indicate that GXR (0.075-0.12 mg/kg/day) was more effective than ATX (1.2 mg/kg/day) in the trial population. The CEA results indicate that GXR is cost effective compared with ATX for the treatment of ADHD in children and adolescents.
Assuntos
Inibidores da Captação Adrenérgica/economia , Agonistas de Receptores Adrenérgicos alfa 2/economia , Transtorno do Deficit de Atenção com Hiperatividade/economia , Guanfacina/economia , Propilaminas/economia , Adolescente , Inibidores da Captação Adrenérgica/uso terapêutico , Agonistas de Receptores Adrenérgicos alfa 2/uso terapêutico , Cloridrato de Atomoxetina , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Criança , Análise Custo-Benefício , Preparações de Ação Retardada , Feminino , Guanfacina/uso terapêutico , Humanos , Masculino , Cadeias de Markov , Propilaminas/uso terapêutico , Anos de Vida Ajustados por Qualidade de Vida , Resultado do TratamentoRESUMO
Neuropathic pain refers to pain that arises as a direct consequence of a lesion or disease affecting the somatosensory nervous system.(1) Many cases of neuropathic pain run a chronic course, and treatment may be difficult because commonly used analgesics, including NSAIDs and to some extent opioids, are often ineffective. In addition, the use of other pharmacological treatments can be limited by unwanted effects. Management requires a multidisciplinary approach and may involve the use of drug therapy (including antidepressants, anticonvulsants and opioids) with non-pharmacological interventions (including psychological therapies, transcutaneous electrical nerve stimulation and interventional procedures). This month and next month we review the drug treatment of neuropathic pain. In this first part we discuss neuropathic pain and the use of antidepressants.
Assuntos
Inibidores da Captação Adrenérgica/administração & dosagem , Antidepressivos Tricíclicos/administração & dosagem , Hiperalgesia/tratamento farmacológico , Neuralgia/tratamento farmacológico , Inibidores Seletivos de Recaptação de Serotonina/administração & dosagem , Inibidores da Captação Adrenérgica/efeitos adversos , Inibidores da Captação Adrenérgica/economia , Antidepressivos Tricíclicos/efeitos adversos , Antidepressivos Tricíclicos/economia , Humanos , Medição da Dor , Guias de Prática Clínica como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Inibidores Seletivos de Recaptação de Serotonina/efeitos adversos , Inibidores Seletivos de Recaptação de Serotonina/economia , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
BACKGROUND: Generic antidepressants offer significant prescription drug cost savings compared with brand-name antidepressants, but critics of managed care interventions promoting generic medication use suggest that some generic antidepressants are not as safe or effective as the brand alternatives. OBJECTIVE: To assess (a) rates of discontinuation of the initially dispensed medication and (b) disease-specific and total health care costs and pharmacy costs, comparing patients who initiated therapy with brand versus generic selective serotonin reuptake inhibitors (SSRI) or selective norepinephrine reuptake inhibitors (SNRI). METHODS: Antidepressant users aged 18 to 64 years with no pharmacy claims for an SSRI/SNRI in the 180 days prior to the start of SSRI/SNRI therapy (baseline) were identified in the MarketScan database between July 1, 2005, and June 30, 2007, and were followed for 180 days (followup). All study patients met the following criteria: (a) continuously eligible from baseline through follow-up; (b) at least 1 medical claim with a primary or secondary diagnosis of major depressive disorder (ICD-9-CM codes 296.2 or 296.3) in either the baseline or follow-up period; and (c) no pharmacy claims for antipsychotic medications in the baseline period. For brand versus generic antidepressant initiators, logistic regression was used to determine the odds of 6-month therapy discontinuation, defined as no medication refills or absence of a refill for the initially dispensed medication within 1.5 times the days supply dispensed, adjusted for important covariates. Costs were measured as total plan allowed charges including member cost share. Adjusted mean (least squares means holding covariates at mean values) all-cause medical costs, disease-specific (claims with a ICD-9-CM diagnosis code for major depressive disorder in the primary or secondary diagnosis field) medical costs, all-cause pharmacy costs, and SSRI/SNRI antidepressant costs were compared for brand versus generic initiators using generalized linear regression models, also adjusted for baseline covariates. RESULTS: Of 16,659 new SSRI/SNRI users, 47.8% (n=7,955) initiated a brand-name medication and 52.2% (n=8,704) initiated a generic product. Of the 7,955 who initiated a brand-name antidepressant, 46.8% (n=3,723) discontinued the initially dispensed drug within 180 days, compared with 44.2% (n=3,843) of the 8,704 who initiated a generic. The adjusted odds of discontinuation among generic and brand drug users did not significantly differ (odds ratio [OR]=1.09, 95% CI=0.98-1.22). Adjusted all-cause 6-month average health care costs in patients initiating therapy on a generic antidepressant were $3,660 (95% CI=$3,538-$3,787) compared with $4,587 (95% CI=$4,422-$4,757) for patients initiating on a brand-name antidepressant. Adjusted average 6-month SSRI/SNRI antidepressant costs were 43.7% lower in patients initiating on a generic drug ($174 vs. $309). CONCLUSIONS: The likelihood of discontinuation was similar for patients who initiated therapy with brand or generic antidepressants, and shortterm health care costs and pharmacy costs were lower in patients starting a generic SSRI/SNRI. The results suggest that the use of generic antidepressants as first-line agents in the treatment of major depressive disorder is associated with continuation rates similar to initiation with brand antidepressants but with lower health care costs.
Assuntos
Inibidores da Captação Adrenérgica/administração & dosagem , Antidepressivos de Segunda Geração/administração & dosagem , Transtorno Depressivo Maior/tratamento farmacológico , Medicamentos Genéricos/administração & dosagem , Inibidores Seletivos de Recaptação de Serotonina/administração & dosagem , Adolescente , Inibidores da Captação Adrenérgica/economia , Adulto , Antidepressivos de Segunda Geração/economia , Estudos de Coortes , Redução de Custos , Bases de Dados Factuais , Custos de Medicamentos , Medicamentos Genéricos/economia , Feminino , Seguimentos , Custos de Cuidados de Saúde , Humanos , Análise dos Mínimos Quadrados , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Inibidores Seletivos de Recaptação de Serotonina/economia , Adulto JovemRESUMO
OBJECTIVE: To examine medication dosing patterns of duloxetine and pregabalin among patients with fibromyalgia. METHODS: From a large US administrative claims database, commercially insured fibromyalgia patients aged 18-64 who initiated duloxetine or pregabalin in 2006 were selected. Initiation was defined as a 90-day medication gap, with the dispense date of the first initiation as the index date. All patients selected had continuous enrollment over the 12-month pre- and post-index periods, and were classified into the duloxetine or pregabalin cohorts based on their index agent. Initial daily dose, average daily dose over the 12-month post-index period, mean and median daily doses and daily costs of each of the first 12 prescriptions were examined for both the duloxetine and pregabalin cohorts. RESULTS: Both the duloxetine (n = 3773) and pregabalin (n = 4189) cohorts had a mean age of 50 years (median age: 52 vs. 53). The average initial daily dose was 55.7 mg for duloxetine and 161.5 mg for pregabalin. Over the 12-month post-index period, the average daily dose per patient was 55.6 mg for duloxetine and 195.7 mg for pregabalin. The average daily doses for the first 12 duloxetine prescriptions ranged 55.7-60.3 mg, with the mean daily costs between $3.77 and $4.59. For the first 12 pregabalin prescriptions, the average daily dose increased from 161.5 mg to 282.4 mg, while the average daily costs ranged between $4.30-4.61. CONCLUSIONS: Among patients with fibromyalgia, duloxetine and pregabalin initiators had different dosing patterns. The average daily dose for duloxetine was relatively stable over time, while pregabalin patients had significant dose increase over the 12-month post-index period.