A cost-effectiveness study of intravenous immunoglobulin in childhood idiopathic thrombocytopenia purpura patients with life-threatening bleeding

Cost-Effectiveness of Second-Line Endocrine Therapies in Postmenopausal Women with Hormone Receptor-positive and Human Epidermal Growth Factor Receptor 2-negative Metastatic Breast Cancer in Japan

BACKGROUND

Exemestane (EXE), exemestane + everolimus (EXE + EVE), toremifene (TOR), and fulvestrant (FUL) are second-line endocrine therapies for postmenopausal hormone receptor-positive (HR +)/human epidermal growth factor receptor 2-negative (HER2 -) metastatic breast cancer (mBC) in Japan. Although the efficacy of these therapies has been shown in recent studies, cost-effectiveness has not yet been determined in Japan.

OBJECTIVE

This study aimed to examine the cost-effectiveness of second-line endocrine therapies for the treatment of postmenopausal women with HR + and HER2 - mBC.

METHODS

A Markov model was developed to analyze the cost-effectiveness of the therapies over a 15-year time horizon from a public healthcare payer's perspective. The efficacy and utility parameters were determined via a systematic search of the literature. Direct medical care costs were used. A discount rate of 2% was applied for costs and outcomes. Subgroup analysis was performed for non-visceral metastasis. A series of sensitivity analyses, including probabilistic sensitivity analysis (PSA) and threshold analysis were performed.

RESULTS

Base-case analyses estimated incremental cost-effectiveness ratios (ICERs) of 3 million and 6 million Japanese yen (JPY)/quality-adjusted life year (QALY) gained for TOR and FUL 500 mg relative to EXE, respectively. FUL 250 mg and EXE + EVE were dominated. The overall survival (OS) highly influenced the ICER. With a willingness-to-pay (WTP) threshold of 5 million JPY/QALY, the probability of TOR being cost-effective was the highest. Subgroup analysis in non-visceral metastasis revealed 0.4 and 10% reduction in ICER from the base-case results of FUL5 500 mg versus EXE and TOR versus EXE, respectively, while threshold analysis indicated EVE and FUL prices should be reduced 73 and 30%, respectively.

CONCLUSION

As a second-line therapy for postmenopausal women with HR +/HER2 - mBC, TOR may be cost-effective relative to other alternatives and seems to be the most favorable choice, based on a WTP threshold of 5 million JPY/QALY. FUL 250 mg is expected to be as costly and effective as EXE. The cost-effectiveness of EXE + EVE and FUL 500 mg could be improved by a large price reduction. However, the results are highly sensitive to the hazard ratio of OS. Policy makers should carefully interpret and utilize these findings.

Economic Evaluation of Intravenous Immunoglobulin plus Corticosteroids for the Treatment of Steroid-Resistant Chronic Inflammatory Demyelinating Polyradiculoneuropathy in Thailand

BACKGROUND AND OBJECTIVE

Intravenous immunoglobulin (IVIG) has been recommended for steroid-resistant chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). The treatment, however, is very costly to healthcare system, and there remains no evidence of its economic justifiability. This study aimed to conduct an economic evaluation (EE) of IVIG plus corticosteroids in steroid-resistant CIDP in Thailand.

METHODS

A Markov model was constructed to estimate the lifetime costs and outcomes for IVIG plus corticosteroids in comparison with immunosuppressants plus corticosteroids in steroid-resistant CIDP patients from a societal perspective. Efficacy and utility data were obtained from clinical literature, meta-analyses, medical record reviews, and patient interviews. Cost data were obtained from list prices, an electronic hospital database, published source, and patient interviews. All costs [in 2015 US dollars (US$)] and outcomes were discounted at 3 % annually. One-way and probabilistic sensitivity analyses were conducted.

RESULTS

In the base-case, the incremental costs and quality-adjusted life years (QALYs) of IVIG plus corticosteroids versus immunosuppressants plus corticosteroids were US$2112.02 and 1.263 QALYs, respectively, resulting in an incremental cost-effectiveness ratio (ICER) of US$1672.71 per QALY gained. Sensitivity analyses revealed that the utility value of disabled patients was the greatest influence on ICER. At a societal willingness-to-pay threshold in Thailand of US$4672 per QALY gained, IVIG plus corticosteroids had a 92.1 % probability of being cost effective.

CONCLUSIONS

At a threshold of US$4672 per QALY gained, IVIG plus corticosteroids is considered a cost-effective treatment for steroid-resistant CIDP patients in Thailand.

Value of Information in Asia: Concepts, Current Use, and Future Directions

Health technology assessment is a form of health policy research that provides policymakers with information relevant to decisions about policy alternatives. Findings from cost-effectiveness analysis (CEA) are one of the important aspects of health technology assessment. Nevertheless, the more advanced method of value of information (VOI), which is recommended by the International Society for Pharmacoeconomics and Outcomes Research and Society for Medical Decision Making Modeling Good Research Practices Task Force, has rarely been applied in CEA studies in Asia. The lack of VOI in Asian CEA studies may be due to limited understanding of VOI methods and what VOI can and cannot help policy decision makers accomplish. This concept article offers audiences a practical primer in understanding the calculation, presentation, and policy implications of VOI. In addition, it provides a rapid survey of health technology assessment guidelines and literature related to VOI in Asia and discusses the future directions of VOI use in Asia and its potential barriers. This article will enable health economists, outcomes researchers, and policymakers in Asia to better understand the importance of VOI analysis and its implications, leading to the appropriate use of VOI in Asia.

Is dosing of therapeutic immunoglobulins optimal? A review of a three-decade long debate in europe

The consumption of immunoglobulins (Ig) is increasing due to better recognition of antibody deficiencies, an aging population, and new indications. This review aims to examine the various dosing regimens and research developments in the established and in some of the relevant off-label indications in Europe. The background to the current regulatory settings in Europe is provided as a backdrop for the latest developments in primary and secondary immunodeficiencies and in immunomodulatory indications. In these heterogeneous areas, clinical trials encompassing different routes of administration, varying intervals, and infusion rates are paving the way toward more individualized therapy regimens. In primary antibody deficiencies, adjustments in dosing and intervals will depend on the clinical presentation, effective IgG trough levels and IgG metabolism. Ideally, individual pharmacokinetic profiles in conjunction with the clinical phenotype could lead to highly tailored treatment. In practice, incremental dosage increases are necessary to titrate the optimal dose for more severely ill patients. Higher intravenous doses in these patients also have beneficial immunomodulatory effects beyond mere IgG replacement. Better understanding of the pharmacokinetics of Ig therapy is leading to a move away from simplistic "per kg" dosing. Defective antibody production is common in many secondary immunodeficiencies irrespective of whether the causative factor was lymphoid malignancies (established indications), certain autoimmune disorders, immunosuppressive agents, or biologics. This antibody failure, as shown by test immunization, may be amenable to treatment with replacement Ig therapy. In certain immunomodulatory settings [e.g., idiopathic thrombocytopenic purpura (ITP)], selection of patients for Ig therapy may be enhanced by relevant biomarkers in order to exclude non-responders and thus obtain higher response rates. In this review, the developments in dosing of therapeutic immunoglobulins have been limited to high and some medium priority indications such as ITP, Kawasaki' disease, Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, myasthenia gravis, multifocal motor neuropathy, fetal alloimmune thrombocytopenia, fetal hemolytic anemia, and dermatological diseases.