A cost-effectiveness analysis of off-label atypical antipsychotic treatment in children and adolescents with ADHD who have failed stimulant therapy.

The objectives of this study are: (1) to estimate the expected health outcomes of atypical antipsychotics (AAPs) and other non-stimulant attention-deficit/hyperactivity disorder (ADHD) medications and (2) to evaluate the cost-effectiveness of AAPs compared to other non-stimulant ADHD medications. We used decision analysis to compare three alternatives for treating children and adolescents with ADHD who failed initial stimulant treatment: (1) AAPs, (2) a selective norepinephrine reuptake inhibitor (atomoxetine), and (3) selective α2-adrenergic agonists (clonidine and guanfacine). Probability estimates and quality-adjusted life year (QALY) weights were derived from a literature review. Cost-effectiveness was estimated using the expected health outcomes derived from the decision analysis and expected costs from the literature. The study was conducted from the third-party payer perspective, and the study period was 1 year. One-way deterministic sensitivity analysis and a Monte Carlo simulation were performed. Over the course of 1 year of ADHD pharmacotherapy, the highest QALY was for clonidine/guanfacine (expected QALY = 0.95) followed by atomoxetine (expected QALY = 0.94). Atypical antipsychotics yielded the lowest health outcome with an expected QALY of 0.84. In the cost-effectiveness analysis, the AAP strategy was dominated as it was less effective and more costly than other two strategies. Compared to clonidine/guanfacine, AAPs provided lower QALYs (0.11 QALY lost) at an additional cost of $2186 on average. Compared to atomoxetine, AAPs resulted in 0.10 QALYs lost at an additional cost of $2186. In this decision analysis model, AAPs provide lower expected health outcomes than other ADHD medications in children and adolescents who failed prior stimulant therapy. Furthermore, AAPs were not a cost-effective option.

Prescribing patterns of anti-migraine medicines in South Africa using a claims database.

BACKGROUND: Migraine is an expensive condition impacting on the economically active sector of the population. Given the expense of anti-migraine medicine, it is important to monitor the impact of generic prescribing and therapeutic substitution. OBJECTIVE: The primary aim was to analyse the prescribing patterns and cost of anti-migraine medicines to determine the impact of generic prescribing and prescribing changes over time. METHOD: A retrospective drug utilisation study was conducted on South African private sector medical insurance claims data for 2011. Results A total of 797 patients received 1583 anti-migraine medicines during 2011. The majority of patients (70.14 %) were females. The average age of patients was 41.61 (SD = 14.91) years. Clonidine was the most frequently prescribed (49.21 % of prescribing frequency; 25.70 % of cost), followed by the triptans [selective serotonin (5-HT1B/1D)-receptor agonists] (27.98 % of prescribing frequency; 45.92 % of cost). Five triptans were prescribed. The average cost per sumatriptan prescription was the lowest (the only triptan with generic equivalents). Rizatriptan was the most frequently prescribed triptan (18.51 % of prescribing frequency; 29.15 % of cost). CONCLUSION: The results were generally in agreement with previous South African studies. The impact of the introduction of newer triptans and of generic equivalents on prescribing patterns was clear.

Randomised controlled study-efficacy of clonidine versus carbamazepine in children with ADHD.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood psychiatric disorder with a prevalence of 8-12%. Even though psychostimulants remain the treatment of choice, its cost and availability in developing countries limits the usage of the drug. In view of free availability and low cost, a Randomized controlled study was carried out using two second line drugs (clonidine and carbamazepine) in a tertiary care hospital, Pondicherry, South India. OBJECTIVE: To compare the efficacy of clonidine and carbamazepine in children with ADHD. METHOD: With approval of ethics committee, a prospective, Double-blind, Randomized controlled study of clonidine and carbamazepine was conducted with 50 children with ADHD (age group 4-12 years), over a period of 2 years (2005-07) in a tertiary care hospital, Pondicherry, South India. RESULTS: Clonidine was effective in improving the hyperactivity and impulsivity symptoms in children with ADHD as compared to carbamazepine. Statistical significant improvement was not noted with respect to inattention symptoms and other comorbid conditions. CONCLUSION: Clonidine can be a safer and cheaper alternative in treatment of children with ADHD, with a predominant effect on their hyperactivity and impulsivity symptoms.

Transdermal clonidine: therapeutic considerations.

Transdermal clonidine was approved by the US Food and Drug Administration in 1984 for the treatment of mild-to-moderate hypertension alone or in combination with a diuretic. Clonidine is released from the patch at a constant rate and thus displays a pharmacokinetic pattern not dissimilar to that of infusion therapy. Transdermal clonidine, like oral clonidine, is effective first- or second-line therapy for most forms of hypertension. More recently, transdermal clonidine has found alternative uses in the areas of smoking cessation, posttraumatic stress disorder, menopausal hot flashes, and alcohol and opiate withdrawal syndromes. The not infrequent development of a dermatitis, together with a substantially greater cost than oral clonidine, have been the major undoings for transdermal clonidine.

Cost-effectiveness comparison of tizanidine and baclofen in the management of spasticity.

OBJECTIVE: Baclofen and tizanidine are both used for the treatment of muscle spasticity of spinal origin. Their effectiveness, cost and adverse-effect profiles differ. This paper sets out to estimate the cost effectiveness of each drug, and the impact of changing from baclofen to tizanidine. DESIGN: A simplified but realistic model of physician behaviour and patient response was developed as a decision tree and populated with data derived from the available published clinical comparative trials. We considered patients with spasticity caused by multiple sclerosis or spinal cord injury. The outcome measure used was 'cost per successfully treated day' (STD). Costs were estimated from the perspective of the UK National Health Service at 2000 values. RESULTS: Expected cost for a cohort of 100 patients over 1 year was estimated to be pound 181 545 with baclofen and pound 211 930 with tizanidine. The estimated number of STDs was 20,192 with tizanidine and 17,289 with baclofen. The overall cost effectiveness of managing spasticity using baclofen and tizanidine was very similar ( pound 10.50 and pound 10.49 per STD respectively). The incremental cost effectiveness (ICE) of using tinzanidine as an alternative to baclofen for first-line treatment was pound 10.47 per STD. Sensitivity analysis found the model to be robust to changes in key parameters CONCLUSION: Drug cost should not be a determining factor in making this treatment choice, as the cost effectiveness ratios are similar for both products.

Nefopam and clonidine in the prevention of postanaesthetic shivering.

Postanaesthetic shivering affects up to 70% of patients after general anaesthesia, and may be very distressing. Various drugs have been used to treat or prevent postanaesthetic shivering, but the ideal one has not yet been found. Sixty patients undergoing elective abdominal or orthopaedic surgery under general anaesthesia were included in a randomised, double-blind study. Patients received clonidine (3 microgram.kg-1), nefopam (0.15 mg.kg-1) or saline 0.9% as a placebo at the end of surgery, prior to extubation. Nefopam and clonidine significantly reduced the incidence and severity of shivering in comparison with the placebo. The recovery time, between the end of anaesthesia and extubation, was significantly longer in the clonidine-treated patients [13.6 (5.2) min] than in either the nefopam [9.6 (2.8) min] or the placebo [10.0 (5.4) min] groups. Mean arterial blood pressure and heart rate were significantly lower in the clonidine group compared with both other groups. Our results suggest that nefopam and clonidine are effective in the prevention of postanaesthetic shivering. However, following clonidine administration the recovery time was prolonged and hypotension was significantly greater than after nefopam.

Pharmacy savings generated by preoperative administration of clonidine.

STUDY OBJECTIVE: To evaluate the effects of the preoperative administration of clonidine by the oral, intramuscular (i.m.), or epidural routes, on isoflurane expense during total abdominal hysterectomy. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: University hospital. PATIENTS: 80 ASA physical status I and II patients scheduled for total abdominal hysterectomy. INTERVENTIONS: Patients were distributed into four groups of treatment: oral, i.m., epidural, and control. Each group received 300 microg clonidine according to the treatment group, plus placebo by the other routes. The control group received placebo by all three routes. Depth of anesthesia was evaluated by changes in blood pressure and heart rate over baseline values. Cost evaluation was based on three components: expense of isoflurane, cost of 300 microg of clonidine (tablets or ampoules), and the disposable material required to dispense clonidine to each group. MEASUREMENTS AND MAIN RESULTS: Groups were comparable regarding demographic data, duration of surgery, and time to discharge from recovery room. Postoperatively, none of the patients had recall of intraoperative events. Clonidine reduced isoflurane pharmacy cost by approximately 45%, regardless of the route of administration. However, when cost of clonidine and the disposable equipment used for its administration were taken into account, the cost of the epidural kit surmounted the savings in isoflurane expense. CONCLUSION: In the patient population studied, premedication with 300 microg oral, i.m., or epidural clonidine, similarly and significantly reduced the expense of isoflurane during general anesthesia of an approximate duration of two hours. However, the cost of the epidural kit offsets the savings in isoflurane.

[The clinical evaluation of some preparations for postoperative epidural anesthesia]. / Klinicheskaia otsenka nekotorykh preparatov dlia posleoperatsionnoi épidural'noi anestezii.

The drugs under study may be disposed as follows according to the efficiency of postoperative epidural anesthesia: pyromecain, clophelin, trimecain-albumin complex. Most effective are clophelin and trimecain-albumin complex. All the three drugs exert an inconsiderable influence on indices of central hemodynamics. The use of clophelin and trimecain-albumin complex reduces loading the medical personnel. Clophelin is most expedient economically.