Health-care costs of losartan and candesartan in the primary treatment of hypertension

Candesartan targeting of angiotensin II type 1 receptor demonstrates benefits for hypertension in pregnancy via the NF‑κB signaling pathway

Hypertensive disorders may be a complication of pregnancy and are characterized by the high blood pressure. Evidence suggests that alterations in the renin-angiotensin-aldosterone system and the sympathetic nervous system are associated with gestational hypertension. Angiotensin II type 1 receptor (Ang-IITR) is a potential target in the progression of gestational hypertension. Candesartan is selective Ang-IITR antagonist that may act against vasoconstriction and reduces peripheral vascular resistance. The aim of the present study was to evaluate the efficacy of Candesartan and the underlying molecular mechanism of the nuclear factor-κB (NF-κB) signaling pathway in the progression of gestational hypertension in a mouse model. Expression and activity of Ang-IITR was evaluated in a mouse model of gestational hypertension prior to and post-treatment of Candesartan both in vitro and in vivo. It was determined whether Candesartan treatment reduces higher blood pressure activated the renal renin-angiotensin system and a prognostic marker, soluble endoglin, and its associated gene in mice with gestational hypertension. Angiotensin-converting enzyme plasma levels and activity were also evaluated in the present study. Cytoplasmic and nuclear immunostaining of NF-κB and associated proteins transforming growth factor β (TGF-β) and endoglin was enhanced in vascular endothelial cells and mice with gestational hypertension. Soluble fms-like tyrosine kinase 1 (sFlt-1), insulin resistance homeostasis model assessment score and associated cardiovascular risk factors also were measured. Results demonstrated that angiotensin and Ang-IITR expression levels were upregulated in mice with gestational hypertension and were downregulated by Candesartan treatment. Renal renin-angiotensin and soluble endoglin were also improved in mice in the Candesartan-treated group. In addition, Candesartan treatment enhanced NF-κB activity, as well as TGF-β and vascular endothelial growth factor expression which led to improved levels of sFlt-1, insulin resistance homeostasis and associated cardiovascular risk factors. Gestational hypertension was markedly improved by treatment of Candesartan compared with the control. In conclusion, the findings of the present study suggested that the NF-κB signaling pathway may be involved in with Candesartan-mediated Ang-IITR for the treatment of gestational hypertension.

Bariatric Surgery can Lead to Net Cost Savings to Health Care Systems: Results from a Comprehensive European Decision Analytic Model

BACKGROUND

The objective of the present study was to evaluate the cost-utility of bariatric surgery in a lifetime horizon from a Swedish health care payer perspective.

METHODS

A decision analytic model using the Markov process was developed covering cardiovascular diseases, type 2 diabetes, and surgical complications. Clinical effectiveness and safety were based on the literature and data from the Scandinavian Obesity Surgery Registry. Gastric bypass, sleeve gastrectomy, and gastric banding were included in the analysis. Cost data were obtained from Swedish sources.

RESULTS

Bariatric surgery was cost saving in comparison with conservative management. It also led to a substantial reduction in lifetime risk of events: from a 16 % reduction in the risk of transient ischaemic attacks to a 62 % reduction in the incidence of type 2 diabetes. Over a lifetime, surgery led to savings of euro 8408 and generated an additional 0.8 years of life and 4.1 quality-adjusted life years (QALYs) per patient, which translates into gains of 32,390 quality-adjusted person-years and savings of euro 66 million for the cohort, operated in 2012. Analysis of the consequences of a 3-year delay in surgery provision showed that the overall lifetime cost of treatment may be increased in patients with diabetes or a body mass index >40 kg/m(2). Delays in surgery may also lead to a loss of clinical benefits: up to 0.6 life years and 1.2 QALYs per patient over a lifetime.

CONCLUSION

Bariatric surgery, over a lifetime horizon, may lead to significant cost savings to health care systems in addition to the known clinical benefits.

The burden of preserved ejection fraction heart failure in a real-world Swedish patient population

OBJECTIVES

To evaluate resource use and associated costs in patients with a diagnosis of heart failure with preserved ejection fraction (HF-PEF) in Sweden.

METHODS

This retrospective study identified real-world patients with an ICD-10 diagnosis code for heart failure (I50) for the period between July 1, 2005 and December 31, 2006 from electronic medical records of primary care centers in Uppsala County Council, and in the Swedish patient registry data. Patients were categorized as having HF-PEF (left ventricle ejection fraction [LVEF] > 50%) during the index period. The study assessed medication utilization, outpatient visits, hospitalizations, and associated healthcare costs, as well as the incidence rates and time to all-cause and heart failure mortality following the index period.

RESULTS

The study included 137 HF-PEF patients with a mean age of 77.1 (SD = 9.1) years. Over 50% of HF-PEF patients were female and hypertensive. Nearly all patients received ≥ 1 medication post-index. Patients had an average of 1.5 heart failure related hospitalizations per follow-up year. The average annual per patient cost for the management of a HF-PEF patient was found in Sweden to be Swedish Krona (SEK) 108,246 (EURO [EUR] 11,344). Hospitalizations contributed to more than 80% of the total cost. All-cause mortality over the 18-month study period was 25.5%, and more than 50% of these deaths occurred within 1 year of index.

LIMITATIONS

Due to the limitations of registry data, it is not possible to confirm the HF diagnosis, and therefore the accuracy of registry records must be assumed. Other factors such as short follow-up time, the study-mandated LVEF assessment, and a lack of drug duration data may also have an impact on the study results.

CONCLUSIONS

All-cause mortality was high in the HF-PEF population, with more than half of patients dying within 1 year of study follow-up. Study results also indicate that 60% of HF-PEF patients have ≥ 1 hospitalization during follow-up. Hospitalizations, especially heart failure related admissions, represent a substantial proportion of the total healthcare burden of patients with HF-PEF in Sweden.

Cost-effectiveness of candesartan versus losartan in the primary preventive treatment of hypertension

Background

Although angiotensin receptor blockers have different receptor binding properties, no comparative randomized studies with cardiovascular event endpoints have been performed for this class of drugs. The aim of this study was to assess the long-term cost-effectiveness of candesartan (Atacand^®) versus generic losartan in the primary preventive treatment of hypertension.

Methods

A decision-analytic model was developed to estimate costs and health outcomes over a patient’s lifetime. Data from a clinical registry study were used to estimate event rates for cardiovascular complications, such as myocardial infarction and heart failure. Costs and quality of life data were from published sources. Costs were in Swedish kronor and the outcome was quality-adjusted life-years (QALYs).

Results

Due to reduced rates of cardiovascular complications, candesartan was associated with a QALY gain and lower health care costs compared with generic losartan (0.053 QALYs gained and reduced costs of approximately 4700 Swedish kronor for women; and 0.057 QALYs gained and reduced costs of approximately 4250 Swedish kronor for men). This result was robust in several sensitivity analyses.

Conclusion

When modeling costs and health outcomes based on event rates for cardiovascular complications from a real-world registry study, candesartan appears to bring a QALY gain and a reduction in costs compared with generic losartan in the primary preventive treatment of hypertension in Sweden.

Resource utilization and cost of heart failure associated with reduced ejection fraction in Swedish patients

AIM

The purpose of this study was to assess healthcare utilization and costs for heart failure patients with reduced ejection fraction (HF-REF) in Sweden.

METHODS AND RESULTS

This was a retrospective, population-based cohort study of patients diagnosed with HF-REF during a period of 18 months at 31 primary care centers in Uppsala County, Sweden. Data was obtained from computerized records from these centers, the Swedish Patient Registry, the Swedish Prescription Registry, the Cause of Death Registry, and a local echocardiography registry maintained by the Department of Physiology, Uppsala University Hospital. Main outcome measures were cardiovascular and heart-failure-related hospitalizations, outpatient visits, medication utilization, mortality (all-cause, cardiovascular, and heart-failure), and healthcare costs for HF-REF patients. During the index period, 252 heart failure patients had a left ventricular ejection fraction measurement ≤ 40% and were categorized as having HF-REF. More than half of the patients had ≥ 1 cardiovascular or heart failure-related hospitalization. On average, patients had >2 such hospitalizations annually. They also averaged ∼1 cardiovascular or heart-failure-related outpatient visit per year. All-cause mortality was high: 15.9% patients died within 1 year after the index date. The mean annual cost per patient for heart-failure-related hospitalizations was SEK 72,613 (EUR 7610). In contrast, annual prescription costs were low, on average 3% of total cost (SEK 3503, EUR 367 per patient)

LIMITATIONS

The main limitations of this study include a short follow-up time and small sample size. Also, certain data were missing, such as echocardiograms (available for only 28% of patients), and information on patients' New York Heart Association (NYHA) functional class, validity period for prescriptions or the units of medication prescribed, and medication dosing. Furthermore, the overall mortality could have been under-estimated, as only the primary cause of death was included in the analysis.

CONCLUSIONS

The main burden associated with HF-REF is related to hospitalizations for heart-failure events. Effective treatment options that decrease hospitalization rates could reduce patients' suffering and potentially offer considerable cost savings.

Long-term clinical and economic outcomes associated with angiotensin II receptor blocker use in hypertensive patients

OBJECTIVE

To examine clinical and economic outcomes associated with angiotensin II receptor blockers (ARB).

METHODS

Retrospective claims data were analyzed for hypertensive adults with ≥1 year follow-up from first ARB claim. Subjects were stratified into four cohorts: olmesartan (OM); valsartan (VAL); losartan (LOS); and irbesartan (IRB), which represented the full sample. Analyses were also conducted with the "limited sample," which excluded subjects with pre-existing conditions in the period before first ARB. Time to follow-up cardiac event was modeled using Cox proportional hazards regression; follow-up healthcare resource utilization and costs were examined using generalized linear models.

RESULTS

The full and limited samples consisted of 118,700 and 65,579 subjects, respectively. Mean follow-up ranged from 861 to 933 days. Baseline characteristics including the Quan-Charlson comorbidity score differed by cohort. In both the full and limited samples, respectively, multivariate models predicted a higher adjusted risk of follow-up cardiac event for VAL cohort (hazard ratio [HR] = 1.261 and 1.242, p < 0.001), LOS cohort (HR = 1.307 and 1.178, p < 0.01), and IRB cohort (HR = 1.222 and 1.179, p ≤ 0.016) compared to OM cohort. Adjusted risk (full sample) of follow-up ambulatory and inpatient visits (all-cause and hypertension-attributable) was higher in VAL, LOS, and IRB cohorts compared to OM. Adjusted risk (limited sample) of follow-up ambulatory visits (all-cause and hypertension-attributable) was greater for VAL, LOS and IRB cohorts relative to OM, but inpatient visit risk was greater only in VAL and LOS cohorts. Compared to the OM cohort, follow-up all-cause adjusted healthcare costs (limited sample) were higher in VAL (cost ratio [CR] = 1.067, p = 0.001) and IRB cohorts (CR = 1.062, p = 0.045).

CONCLUSIONS

In this large national US health plan, treatment with OM was associated with lower risk of cardiac events and lower healthcare resource utilization and costs versus VAL, LOS, and IRB over a mean follow-up of 2.5 years. Association, rather than causality, to cardiac outcomes may be inferred from these observational claims data.