RESUMO
There are many new treatment options available for migraine and more are coming. Three calcitonin gene-related peptide (CGRP) antagonist monoclonal antibodies have been approved and a 4th is due in early 2020. Small molecule CGRP receptor-blocking oral compounds, both for acute care and prevention, are also coming. Four neurostimulators are available, with others on the way. New acute treatments coming soon include the 5HT1F agonist lasmiditan, a zolmitriptan intradermal micro-needle patch, and a nasal mist sumatriptan with a permeability enhancer. Farther out, three novel dihydroergotamine delivery systems, and a liquid-filled capsule of celecoxib show early promise. A new, safer form of methysergide is in the works, as is a longer-duration onabotulinumtoxinA. As always with new products, questions regarding safety, tolerability, cost, and insurance coverage will need to be addressed. Despite these concerns and uncertainties, a robust headache treatment pipeline is good for patients who are not satisfied with the results of their treatment and/or cannot tolerate existing treatments.
Assuntos
Analgésicos não Narcóticos/uso terapêutico , Anticorpos Monoclonais/uso terapêutico , Antagonistas do Receptor do Peptídeo Relacionado ao Gene de Calcitonina/uso terapêutico , Inibidores de Ciclo-Oxigenase 2/uso terapêutico , Terapia por Estimulação Elétrica , Transtornos de Enxaqueca/terapia , Agonistas do Receptor 5-HT1 de Serotonina/uso terapêutico , Estimulação Magnética Transcraniana , Vasoconstritores/uso terapêutico , Analgésicos não Narcóticos/administração & dosagem , Analgésicos não Narcóticos/efeitos adversos , Analgésicos não Narcóticos/economia , Anticorpos Monoclonais/administração & dosagem , Anticorpos Monoclonais/efeitos adversos , Anticorpos Monoclonais/economia , Antagonistas do Receptor do Peptídeo Relacionado ao Gene de Calcitonina/administração & dosagem , Antagonistas do Receptor do Peptídeo Relacionado ao Gene de Calcitonina/efeitos adversos , Antagonistas do Receptor do Peptídeo Relacionado ao Gene de Calcitonina/economia , Inibidores de Ciclo-Oxigenase 2/administração & dosagem , Inibidores de Ciclo-Oxigenase 2/efeitos adversos , Inibidores de Ciclo-Oxigenase 2/economia , Humanos , Transtornos de Enxaqueca/tratamento farmacológico , Agonistas do Receptor 5-HT1 de Serotonina/administração & dosagem , Agonistas do Receptor 5-HT1 de Serotonina/efeitos adversos , Agonistas do Receptor 5-HT1 de Serotonina/economia , Vasoconstritores/administração & dosagem , Vasoconstritores/efeitos adversos , Vasoconstritores/economiaRESUMO
BACKGROUND: Patients with distributive shock who are unresponsive to traditional vasopressors are commonly considered to have severe distributive shock and are at high mortality risk. Here, we assess the cost-effectiveness of adding angiotensin II to the standard of care (SOC) for severe distributive shock in the US critical care setting from a US payer perspective. METHODS: Short-term mortality outcomes were based on 28-day survival rates from the ATHOS-3 study. Long-term outcomes were extrapolated to lifetime survival using individually estimated life expectancies for survivors. Resource use and adverse event costs were drawn from the published literature. Health outcomes evaluated were lives saved, life-years gained, and quality-adjusted life-years (QALYs) gained using utility estimates for the US adult population weighted for sepsis mortality. Deterministic and probabilistic sensitivity analyses assessed uncertainty around results. We analyzed patients with severe distributive shock from the ATHOS-3 clinical trial. RESULTS: The addition of angiotensin II to the SOC saved .08 lives at Day 28 compared to SOC alone. The cost per life saved was estimated to be $108,884. The addition of angiotensin II to the SOC was projected to result in a gain of .96 life-years and .66 QALYs. This resulted in an incremental cost-effectiveness ratio of $12,843 per QALY. The probability of angiotensin II being cost-effective at a threshold of $50,000 per QALY was 86 percent. CONCLUSIONS: For treatment of severe distributive shock, angiotensin II is cost-effective at acceptable thresholds.
Assuntos
Angiotensina II/economia , Angiotensina II/uso terapêutico , Unidades de Terapia Intensiva , Choque/tratamento farmacológico , Vasoconstritores/economia , Vasoconstritores/uso terapêutico , Adulto , Idoso , Angiotensina II/administração & dosagem , Análise Custo-Benefício , Quimioterapia Combinada , Feminino , Humanos , Expectativa de Vida , Masculino , Pessoa de Meia-Idade , Modelos Econométricos , Escores de Disfunção Orgânica , Anos de Vida Ajustados por Qualidade de Vida , Índice de Gravidade de Doença , Choque/mortalidade , Choque/terapia , Estados Unidos , Vasoconstritores/administração & dosagemRESUMO
OBJECTIVES: Hepatorenal syndrome (HRS) is a functional renal failure occurring in end stage liver disease, which is associated with poor prognosis. Terlipressin has been shown to be effective in treatment of HRS. More recently, it was suggested that noradrenaline, an alpha-adrenergic drug may be also effective in HRS. We aimed to compare the efficacy of noradrenaline versus terlipressin in treatment of HRS type 1. METHODS: Consecutive patients with cirrhosis and HRS type 1 were enrolled and randomised into 2 groups- Group A received intravenous noradrenaline infusion (0.5-3 mg/h) and group B received intravenous terlipressin (0.5-2 mg/6h) for 2 weeks. Intravenous albumin (20 g/day) was given to both groups. RESULTS: Out of 55 cirrhotics screened, 41 were randomised into group A (n=21) or group B (n=20). Baseline characteristics of the two groups were similar. HRS reversal was seen in 47.6%(10/21) patients in group A, and 45% (9/20) patients in group B (p=1.00). In both groups, there was a significant decrease in serum creatinine from baseline (group A- 3.1±1.4 mg/dl to 2.2±1.3 mg/dl, p=0.028; group B- 3.4±1.6 mg/dl to 2.3±1.3 mg/dl, p=0.035). Both the groups showed a significant increase in mean arterial pressure (group A- 77.3±8.6 mmHg to 103.4±8.3 mmHg, p=0.0001; group B- 76.8±11.6 mmHg to 100±9.4 mmHg, p=0.0001). Noradrenaline was associated with fewer adverse events and was significantly cheaper than terlipressin. Lower baseline MELD score was an independent predictor of response to treatment. CONCLUSIONS: Noradrenaline is as effective and safe as terlipressin in the treatment of HRS type 1.
Assuntos
Agonistas alfa-Adrenérgicos/uso terapêutico , Síndrome Hepatorrenal/tratamento farmacológico , Lipressina/análogos & derivados , Norepinefrina/uso terapêutico , Vasoconstritores/uso terapêutico , Agonistas alfa-Adrenérgicos/economia , Creatinina/sangue , Feminino , Síndrome Hepatorrenal/etiologia , Humanos , Cirrose Hepática/complicações , Lipressina/economia , Lipressina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Norepinefrina/economia , Estudos Prospectivos , Terlipressina , Vasoconstritores/economiaAssuntos
Anafilaxia/tratamento farmacológico , Custos de Medicamentos , Epinefrina/administração & dosagem , Epinefrina/economia , Injeções/instrumentação , Agonistas Adrenérgicos/administração & dosagem , Agonistas Adrenérgicos/economia , Anafilaxia/economia , Broncodilatadores/administração & dosagem , Broncodilatadores/economia , Comércio , Recall de Medicamento , Humanos , Estados Unidos , Vasoconstritores/administração & dosagem , Vasoconstritores/economiaRESUMO
BACKGROUND: Care for pediatric patients with headache often occurs in high-cost settings such as emergency departments (EDs) and inpatient settings. Outpatient infusion centers have the potential to reduce care costs for pediatric headache management. METHODS: In this quality improvement study, we describe our experience in creating the capacity to support an integrated outpatient pediatric headache infusion care model through an infusion center. We compare costs of receiving headache treatment in this model with those in the emergency and inpatient settings. Because dihydroergotamine (DHE) is a costly infusion, encounters at which DHE was administered were analyzed separately. We track the number of ED visits and inpatient admissions for headache using run charts. As a balancing measure, we compare treatment efficacy between the infusion care model and the inpatient setting. RESULTS: The mean percentage increase in cost of receiving headache treatment in the inpatient setting with DHE was 61% (confidence interval [CI]: 30-99%), and that without DHE was 582% (CI: 299-1068%) compared with receiving equivalent treatments in the infusion center. The mean percentage increase in cost of receiving headache treatment in the ED was 30% (CI: -15 to 100%) compared with equivalent treatment in the infusion center. After the intervention, ED visits and inpatient admissions for headache decreased. The mean change in head pain was similar across care settings. CONCLUSIONS: Our findings demonstrate that developing an integrated ambulatory care model with infusion capacity for refractory pediatric headache is feasible, and our early outcomes suggest this may have a favorable impact on the overall value of care for this population.
Assuntos
Assistência Ambulatorial , Di-Hidroergotamina , Transtornos da Cefaleia/tratamento farmacológico , Modelos Organizacionais , Avaliação de Processos em Cuidados de Saúde , Melhoria de Qualidade , Vasoconstritores , Fluxo de Trabalho , Adolescente , Assistência Ambulatorial/economia , Assistência Ambulatorial/organização & administração , Assistência Ambulatorial/normas , Criança , Di-Hidroergotamina/administração & dosagem , Di-Hidroergotamina/economia , Estudos de Viabilidade , Humanos , Encaminhamento e Consulta , Vasoconstritores/administração & dosagem , Vasoconstritores/economiaRESUMO
PURPOSE: To determine the cost-effectiveness of escalating doses of norepinephrine or norepinephrine plus the adjunctive use of vasopressin or angiotensin II as a second-line vasopressor for septic shock. MATERIALS AND METHODS: Decision tree analysis was performed to compare costs and outcomes associated with norepinephrine monotherapy or the two adjunctive second-line vasopressors. Short- and long-term outcomes modeled included ICU survival and lifetime quality-adjusted-life-years (QALY) gained. Costs were modeled from a payer's perspective, with a willingness-to-pay threshold set at $100,000/unit gained. One-way (tornado diagrams) and probabilistic sensitivity analyses were performed. RESULTS: Adjunctive vasopressin was the most cost-effective therapy, and dominated both norepinephrine monotherapy and adjunctive angiotensin II by producing higher ICU survival at less cost. For the lifetime horizon, while norepinephrine monotherapy was least expensive, adjunctive vasopressin was the most cost-effective with an incremental cost-effectiveness ratio of $19,762 / QALY gained. Although adjunctive angiotensin II produced more QALYs compared to norepinephrine monotherapy, it was dominated in the long-term evaluation by second-line vasopressin. Sensitivity analyses demonstrated model robustness and medication costs were not significant drivers of model results. CONCLUSIONS: Vasopressin is the most cost-effective second-line vasopressor in both the short- and long-term evaluations. Vasopressor price is a minor contributor to overall cost.
Assuntos
Norepinefrina/administração & dosagem , Choque Séptico/tratamento farmacológico , Vasoconstritores/administração & dosagem , Vasopressinas/administração & dosagem , Análise Custo-Benefício , Quimioterapia Combinada , Humanos , Norepinefrina/economia , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Estados Unidos , Vasoconstritores/economia , Vasopressinas/economiaRESUMO
PURPOSE: Mortality rate for septic shock, despite advancements in knowledge and treatment, remains high. Treatment includes administration of broad-spectrum antibiotics and stabilization of the mean arterial pressure (MAP) with intravenous fluid resuscitation. Fluid-refractory shock warrants vasopressor initiation. There is a paucity of evidence regarding the timing of vasopressor initiation and its effect on patient outcomes. MATERIALS AND METHODS: This retrospective, single-centered, cohort study included patients with septic shock from January 2017 to July 2017. Time from initial hypotension to vasopressor initiation was measured for each patient. The primary outcome was 30-day mortality. RESULTS: Of 530 patients screened,119 patients were included. There were no differences in baseline patient characteristics. Thirty-day mortality was higher in patients who received vasopressors after 6â¯h (51.1% vs 25%, pâ¯<â¯.01). Patients who received vasopressors within the first 6â¯h had more vasopressor-free hours at 72â¯h (34.5â¯h vs 13.1, pâ¯=â¯.03) and shorter time to MAP of 65â¯mmHg (1.5â¯h vs 3.0, pâ¯<â¯.01). CONCLUSION: Vasopressor initiation after 6â¯h from shock recognition is associated with a significant increase in 30-day mortality. Vasopressor administration within 6â¯h was associated with shorter time to achievement of MAP goals and higher vasopressor-free hours within the first 72â¯h.
Assuntos
Hipotensão/tratamento farmacológico , Norepinefrina/administração & dosagem , Choque Séptico/mortalidade , Tempo para o Tratamento , Vasoconstritores/uso terapêutico , Vasopressinas/administração & dosagem , Idoso , Pressão Arterial , Análise Custo-Benefício , Hidratação , Custos de Cuidados de Saúde , Humanos , Norepinefrina/economia , Anos de Vida Ajustados por Qualidade de Vida , Ressuscitação , Estudos Retrospectivos , Choque Séptico/tratamento farmacológico , Vasoconstritores/economia , Vasopressinas/economiaRESUMO
In about 20% of chronic cluster headache (CH) cases, drugs may become ineffective. Under these circumstances, steroids and triptans are frequently employed leading to fearful side effects in one and high costs in the other. The direct costs of drug-resistant chronic CH are mainly due to frequent medical consultations and frequent use of expensive drugs. In recent years, hypothalamic stimulation has been employed to treat drug-resistant chronic CH patients suffering multiple daily attacks and long-term results from different centres show a 60% overall benefit. Nine years since the introduction of this technique, we attempt a preliminary analysis of the direct costs of hypothalamic stimulation based on patients treated at our centre. We estimated the following direct costs as follows: cost of neurosurgery plus cost of equipment (electrode, connection and impulse generator = 25,000 euro), cost of hospital admissions in long-term follow-up (2,000 euro per admission), cost of single sumatriptan injection (25 euro). Number of daily sumatriptan injections in the year before and for each year after hypothalamic implantation was obtained from headache diaries. To estimate the saving due to the reduction in sumatriptan consumption following hypothalamic stimulation, we calculated the following for each year of follow-up after surgery: number of sumatriptan injections in the year before surgery minus number of sumatriptan injections in each year, updated to December 2008. In our 19 implanted patients, the costs of neurosurgery plus cost of equipment were 475,000 euro; the costs of hospital admissions during follow up were 250,000 euro. Reduction in sumatriptan consumption resulted in a total saving of 3,573,125 euro. Hence, in our 19 patients, the sumatriptan saving (3,573,125 euro) minus the direct costs due to operation and follow up hospitalisations (475,000 + 250,000) euro is equal to 2,848,125 euro. These preliminary results indicate that hypothalamic stimulation is associated with marked reduction of direct costs in the management of complete drug-resistant chronic CH.
Assuntos
Cefaleia Histamínica/economia , Cefaleia Histamínica/terapia , Estimulação Encefálica Profunda/economia , Hipotálamo , Adulto , Cefaleia Histamínica/cirurgia , Resistência a Medicamentos , Eletrônica Médica/economia , Feminino , Seguimentos , Custos de Cuidados de Saúde , Hospitalização/economia , Humanos , Masculino , Procedimentos Neurocirúrgicos/economia , Sumatriptana/economia , Sumatriptana/uso terapêutico , Vasoconstritores/economia , Vasoconstritores/uso terapêuticoRESUMO
BACKGROUND: Septic shock therapies that shorten the time to physiologic and clinical recovery may result in financial savings. However, the financial implications of improving these nonmortal outcomes are not well characterized. Therefore, we quantified hospital charges associated with four outcomes: ICU length of stay, duration of invasive mechanical ventilation, duration of vasopressor use, and new renal replacement therapy. METHODS: This was an observational study using administrative data from a large academic hospital in the United States. The analysis included adults treated with vasopressors for septic shock in a medical ICU. Linear regression modeling with ordinary least square was used to estimate the incremental hospital charges associated with 1 day of ICU length of stay, 1 day of mechanical ventilation, 1 day of vasopressor use, and new renal replacement therapy. RESULTS: The study population included 587 adults with septic shock, including 180 (30.7%) who died in the hospital. The median charge for a septic shock hospitalization was $98,583 (interquartile range [IQR], $61,177-$136,672). Decreases in ICU length of stay, mechanical ventilation duration, and vasopressor duration of 1 day were associated with charge reductions of $15,670 (IQR, $15,023-$16,317), $15,284 (IQR, $13,566-$17,002), and $17,947 (IQR, $16,344-$19,549), respectively. Avoidance of new renal replacement therapy was associated with a charge reduction of $36,051 (IQR, $22,353-$49,750). CONCLUSIONS: Septic shock therapies that reduce the duration of organ support and ICU care have the potential to lead to substantial financial savings.
Assuntos
Cuidados Críticos/economia , Preços Hospitalares , Tempo de Internação/economia , Choque Séptico/economia , Choque Séptico/terapia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Diálise Renal/economia , Respiração Artificial/economia , Estudos Retrospectivos , Vasoconstritores/economia , Vasoconstritores/uso terapêuticoRESUMO
PURPOSE: Hyperinflation refers to the increasing cost of drugs which occurs due to continued drug shortages and rebranding. Hyperinflation has significant implications in increasing overall healthcare costs with reduced reimbursement, increased patient acuity, and an aging population, but published strategies to reduce costs and minimize waste are limited. OBJECTIVE: To describe the hyperinflation and cost mitigation strategies of three vasopressor medications, vasopressin, epinephrine, and ephedrine. CONCLUSION: The steep increase in medications is expected to continue, and mitigation strategies to reduce waste and select the most cost effective therapy to offset the price increase is crucial for healthcare systems.
Assuntos
Controle de Custos , Custos de Medicamentos/tendências , Inflação , Vasoconstritores/economia , Efedrina/economia , Epinefrina/economia , Humanos , Inflação/tendências , Vasopressinas/economiaRESUMO
Anaphylaxis is an allergic reaction that occurs rapidly after exposure and is life-threatening. After symptoms of anaphylaxis occur, there is no way to reliably predict whether the patient's condition could progress quickly and become life-threatening. Immediate injection of intramuscular epinephrine is the first-line emergency treatment for anaphylaxis. Other drugs such as corticosteroids or antihistamines are secondary options and should not delay epinephrine administration. The most commonly prescribed form of epinephrine is the costly brand name autoinjector, but less expensive alternatives exist, including generic autoinjectors and prefilled epinephrine syringes. Epinephrine prescriptions should be combined with action plans that guide parents and caregivers on appropriate use. Access to epinephrine at schools, even for students who do not have a prescription, is an important component of preparedness for anaphylaxis.
Assuntos
Anafilaxia/diagnóstico , Anafilaxia/tratamento farmacológico , Broncodilatadores/uso terapêutico , Epinefrina/uso terapêutico , Vasoconstritores/uso terapêutico , Anafilaxia/etiologia , Broncodilatadores/administração & dosagem , Broncodilatadores/economia , Epinefrina/administração & dosagem , Epinefrina/economia , Humanos , Vasoconstritores/administração & dosagem , Vasoconstritores/economiaRESUMO
Objective We examined whether patients with a positive SeptiFast (SF) assay (LightCycler SeptiFast; Roche Diagnostics, Basel, Switzerland) developed higher long-term mortality, a more difficult course of treatment, and a higher antimicrobial treatment cost than patients with a negative SF assay. Methods We performed a post-hoc analysis of data collected in a 1-year prospective interventional study of adults with severe sepsis and septic shock. In addition to the standard treatment, an additional 5 ml of blood was obtained for an SF assay, and the antimicrobial treatment was changed according to the SF results. Results We included 57 patients, and the SF assay was positive (SF+) in 10 (17.5%) and negative (SF-) in 47 (82.5%) patients. A trend toward a higher 6-month, 1-year, and 2-year mortality rate was observed in the SF+ group. In the SF+ group, we observed a significantly greater need for second-line vasopressor therapy, a higher initial procalcitonin concentration, and higher maximum C-reactive protein and lactate concentrations. We found no significant differences in cost of antimicrobial treatment between the SF+ and SF- groups. Conclusions We observed a trend toward higher long-term mortality and a more difficult course of treatment but no difference in the cost of antimicrobial treatment.
Assuntos
Antibacterianos/economia , Bacteriemia/tratamento farmacológico , DNA Bacteriano/genética , Reação em Cadeia da Polimerase/métodos , Sepse/tratamento farmacológico , Idoso , Antibacterianos/uso terapêutico , Bacteriemia/economia , Bacteriemia/microbiologia , Bacteriemia/mortalidade , Proteína C-Reativa/metabolismo , Calcitonina/sangue , DNA Bacteriano/efeitos dos fármacos , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sepse/economia , Sepse/microbiologia , Sepse/mortalidade , Análise de Sobrevida , Vasoconstritores/economia , Vasoconstritores/uso terapêuticoAssuntos
Epinefrina/efeitos adversos , Traumatismos da Mão/cirurgia , Lidocaína/efeitos adversos , Traumatismos dos Tendões/cirurgia , Vasoconstritores/efeitos adversos , Acidentes de Trabalho , Anestésicos Locais/administração & dosagem , Anestésicos Locais/efeitos adversos , Anestésicos Locais/economia , Estabilidade de Medicamentos , Epinefrina/administração & dosagem , Epinefrina/economia , Humanos , Lidocaína/administração & dosagem , Lidocaína/economia , Masculino , Pessoa de Meia-Idade , Fentolamina/administração & dosagem , Fatores de Risco , Torniquetes , Vasoconstritores/administração & dosagem , Vasoconstritores/economiaRESUMO
BACKGROUND: Anesthesia drugs can be prepared by anesthesia providers, hospital pharmacies or outsourcing facilities. The decision whether to outsource all or some anesthesia drugs is challenging since the costs associated with different anesthesia drug preparation methods remain poorly described. METHODS: The costs associated with preparation of 8 commonly used anesthesia drugs were analyzed using a budget impact analysis for 4 different syringe preparation strategies: (1) all drugs prepared by anesthesiologist, (2) drugs prepared by anesthesiologist and hospital pharmacy, (3) drugs prepared by anesthesiologist and outsourcing facility, and (4) all drugs prepared by outsourcing facility. MAIN RESULTS: A strategy combining anesthesiologist and hospital pharmacy prepared drugs was associated with the lowest estimated annual cost in the base-case budget impact analysis with an annual cost of $225 592, which was lower than other strategies by a margin of greater than $86 000. CONCLUSION: A combination of anesthesiologist and hospital pharmacy prepared drugs resulted in the lowest annual cost in the budget impact analysis. However, the cost of drugs prepared by an outsourcing facility maybe lower if the capital investment needed for the establishment and maintenance of the US Pharmacopeial Convention Chapter <797> compliant facility is included in the budget impact analysis.
Assuntos
Anestesia/economia , Anestésicos/economia , Custos de Medicamentos/estatística & dados numéricos , Serviços Terceirizados/economia , Serviço de Farmácia Hospitalar/economia , Anestesiologistas , District of Columbia , Composição de Medicamentos/economia , Composição de Medicamentos/métodos , Humanos , Modelos Econométricos , Fármacos Neuromusculares Despolarizantes/economia , Seringas , Vasoconstritores/economiaRESUMO
Wide awake hand surgery employs local-only anesthesia with low-dose epinephrine to create a bloodless field without the use of an arm tourniquet. Despite traditional teaching, evidence-based medicine suggests epinephrine is safe for use in hand and digital anesthesia. Eliminating an arm tourniquet reduces the requirement for sedation and general anesthetic. This confers particular advantage in surgeries such as tendon repairs, tendon transfers, and soft tissue releases in which intraoperative active motion can used to optimize outcomes. The wide awake approach also confers significant benefit to patients, providers, and health care systems alike due to efficiencies and cost savings.
Assuntos
Anestesia Local/métodos , Anestésicos Locais/administração & dosagem , Procedimentos Médicos e Cirúrgicos sem Sangue/métodos , Epinefrina/administração & dosagem , Mãos/irrigação sanguínea , Mãos/cirurgia , Procedimentos Ortopédicos/métodos , Vasoconstritores/administração & dosagem , Vigília , Anestesia Local/efeitos adversos , Anestesia Local/economia , Anestésicos Locais/efeitos adversos , Anestésicos Locais/economia , Procedimentos Médicos e Cirúrgicos sem Sangue/efeitos adversos , Procedimentos Médicos e Cirúrgicos sem Sangue/economia , Redução de Custos , Análise Custo-Benefício , Epinefrina/efeitos adversos , Epinefrina/economia , Custos de Cuidados de Saúde , Humanos , Injeções , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/economia , Satisfação do Paciente , Complicações Pós-Operatórias/etiologia , Fluxo Sanguíneo Regional , Resultado do Tratamento , Vasoconstritores/efeitos adversos , Vasoconstritores/economiaAssuntos
Transtornos de Enxaqueca/economia , Farmácias/economia , Sumatriptana/economia , Sumatriptana/uso terapêutico , Vasoconstritores/economia , Humanos , Transtornos de Enxaqueca/tratamento farmacológico , Preparações Farmacêuticas/economia , Farmácias/tendências , Vasoconstritores/uso terapêuticoRESUMO
BACKGROUND: - Terlipressin and noradrenaline are the best studied treatments for hepatorenal syndrome, and there is no evidence of superiority of one over the other regarding to efficacy. While the former drug is more costly, the latter requires admission into an intensive care unit. OBJECTIVE: - The aim of this study was to perform an economic evaluation, comparing treatments for hepatorenal syndrome with terlipressin and noradrenaline. METHODS: - For the economic evaluation, a cost-minimization analysis was performed. Direct medical costs of the two treatment strategies were compared under the perspective of the Brazilian Public Health System as the third-party payer. A probabilistic sensitivity analysis was performed. RESULTS: - The costs of treatments with terlipressin or noradrenaline were 287.77 and 2,960.45 International Dollars (Int$) respectively. Treatment using terlipressin would save Int$2,672.68 for the Public Health System for each hospital admission related to hepatorenal syndrome. In the probabilistic sensitivity analysis, it was verified that the cost of the treatment with noradrenaline could vary between Int$2,326.53 and Int$3,644.16, while costs related to the treatment using terlipressin are not variable. CONCLUSION: - The treatment strategy using terlipressin was more economical than that using noradrenaline under the perspective of the Brazilian Public Health System as the third-party payer.
Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Síndrome Hepatorrenal/economia , Lipressina/análogos & derivados , Norepinefrina/economia , Saúde Pública/economia , Vasoconstritores/economia , Brasil , Análise Custo-Benefício , Síndrome Hepatorrenal/tratamento farmacológico , Humanos , Lipressina/economia , Lipressina/uso terapêutico , Norepinefrina/uso terapêutico , Terlipressina , Resultado do Tratamento , Vasoconstritores/uso terapêuticoRESUMO
OBJECTIVE: The aim of this study was to compare the efficacy and costs of terlipressin and noradrenaline for the treatment of hepatorenal syndrome from the perspective of the Brazilian public health system and that of a major private health insurance. METHODS: Comparison of efficacy was performed through a systematic review with a meta-analysis of randomized-controlled trials using a random-effects model. Economic evaluation was carried out through cost minimization. RESULTS: Four studies (154 patients) were included in the meta-analysis. There was no evidence of a difference between treatments with terlipressin or noradrenaline in terms of 30-day survival (risk ratio=1.04, 95% confidence interval=0.84-1.30, P=0.70). From the perspective of the public health system, costs of the treatments with terlipressin or noradrenaline were Int$7437.04 and Int$8406.41, respectively. From the perspective of the private health insurance, costs of treatments with terlipressin and noradrenaline were Int$13,484.57 and Int$15,061.01, respectively. CONCLUSION: There was no evidence of superiority between treatment strategies using terlipressin or noradrenaline in terms of the survival of patients with hepatorenal syndrome, but the strategy using terlipressin was more economical under two different perspectives.
Assuntos
Custos de Medicamentos , Síndrome Hepatorrenal/tratamento farmacológico , Síndrome Hepatorrenal/economia , Lipressina/análogos & derivados , Norepinefrina/economia , Norepinefrina/uso terapêutico , Vasoconstritores/economia , Vasoconstritores/uso terapêutico , Brasil , Distribuição de Qui-Quadrado , Redução de Custos , Análise Custo-Benefício , Síndrome Hepatorrenal/diagnóstico , Síndrome Hepatorrenal/mortalidade , Humanos , Lipressina/efeitos adversos , Lipressina/economia , Lipressina/uso terapêutico , Modelos Econômicos , Norepinefrina/efeitos adversos , Razão de Chances , Ensaios Clínicos Controlados Aleatórios como Assunto , Terlipressina , Resultado do Tratamento , Vasoconstritores/efeitos adversosRESUMO
Hepatorenal syndrome is a condition associated with very high mortality that may be reverted in some cases with vasoconstrictors. Terlipressin has generally been considered standard treatment, but noradrenaline has been postulated as alternative. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified six systematic reviews including four pertinent randomized controlled trials. We combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded noradrenaline and terlipressin probably have similar effects on reverting hepatorrenal syndrome and decreasing mortality, but noradrenaline is associated with less adverse effects, and has lower costs.
El síndrome hepatorrenal es una condición asociada a altísima mortalidad, que puede ser recuperada en ciertos casos con el uso de vasoconstrictores. Generalmente se considera que terlipresina es el tratamiento estándar, pero noradrenalina se ha planteado como una alternativa. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en 30 bases de datos, identificamos seis revisiones sistemáticas que en conjunto incluyen cuatro estudios aleatorizados. Realizamos un metanálisis y tablas de resumen de los resultados utilizando el método GRADE. Concluimos que noradrenalina y terlipresina son probablemente igual de efectivas en lograr mejoría del síndrome hepatorrenal y disminuir la mortalidad, pero que noradrenalina se asocia a menos efectos adversos, y tiene un menor costo.
Assuntos
Síndrome Hepatorrenal/tratamento farmacológico , Lipressina/análogos & derivados , Norepinefrina/uso terapêutico , Custos de Medicamentos , Síndrome Hepatorrenal/mortalidade , Síndrome Hepatorrenal/fisiopatologia , Humanos , Lipressina/efeitos adversos , Lipressina/economia , Lipressina/uso terapêutico , Norepinefrina/efeitos adversos , Norepinefrina/economia , Ensaios Clínicos Controlados Aleatórios como Assunto , Terlipressina , Vasoconstritores/efeitos adversos , Vasoconstritores/economia , Vasoconstritores/uso terapêuticoRESUMO
BACKGROUND: Early treatment of migraine with sumatriptan 50 mg and 100 mg, while pain is mild, has been reported to enhance pain-free response 2 hours and 4 hours postdose and sustained pain-free response 2 to 24 hours postdose compared with treatment when pain has become moderate to severe. Early treatment with sumatriptan 50 mg and 100 mg also resulted in less redosing, which translated to a reduction in the mean number of doses used per migraine episode. OBJECTIVE: We examined the economic implications of early treatment with sumatriptan 50 mg and 100 mg while pain is mild versus treatment when pain has become moderate to severe. METHODS: Using data from retrospective analyses of a dose-ranging clinical trial of sumatriptan (protocol S2CM09) involving 1003 patients, we estimated the mean cost per treatment success for a hypothetical population of 1000 migraine patients who received treatment with sumatriptan 50-mg or 100-mg tablets early while pain was mild versus treatment when pain had become moderate to severe. RESULTS: With a conservative estimate of migraine frequency of 1.5 episodes per month, the total cost of early migraine treatment with sumatriptan 50 mg and 100 mg was reduced by $31.68 and $20.16, respectively, per patient per year. The average cost per pain-free treatment success was reduced by 32% to 57% with sumatriptan 50 mg and 100 mg if migraines were treated while pain was mild in intensity versus when pain had become moderate to severe. CONCLUSIONS: Treatment of migraine with sumatriptan 50-mg and 100-mg tablets is effective regardless of whether pain is mild, moderate, or severe. However, initiating treatment while pain is mild may be more cost-effective than delaying treatment until pain has become moderate to severe.