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Pungprasert T, Dhirachaikulpanich D, Phutthasakda W, Tantai N, Maneeon S, Nganthavee V, Atipas K, Tanpong S, Krithin S, Tanglitanon S, Jutidamrongphan W, Chayakulkeeree M, Srinonprasert V, Phikulsod P. The cost-utility analysis of antifungal prophylaxis for invasive fungal infections in acute myeloid leukaemia patients receiving chemotherapy: a study from a middle-income country. J Hosp Infect 2024; 145:118-128. [PMID: 38219835 DOI: 10.1016/j.jhin.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 12/15/2023] [Accepted: 12/25/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Invasive fungal infections (IFIs) contribute to morbidity and mortality during acute myeloid leukaemia (AML) treatment. Without prophylaxis, IFI rate during AML treatment in Thailand is high and results in a high mortality rate and a prolonged hospital stay. AIM To evaluate the cost-utility of antifungal therapy (AFT) prophylaxis during AML treatment. METHODS We assessed the cost-utility of AFT available in Thailand, including posaconazole (solution), itraconazole (solution and capsule), and voriconazole. A hybrid model consisting of a decision tree and the Markov model was established. RESULTS The costs to prevent overall IFI using any AFT were all lower than the treatment cost of a non-prophylaxis group, resulting in a saving of 808-1507 USD per patient. Prevention with voriconazole prophylaxis showed the highest quality-adjusted life years (QALYs = 3.51, incremental QALYs = 0.23), followed by posaconazole (QALYs = 3.46, incremental QALY = 0.18) and itraconazole solution (QALYs = 3.45, incremental QALYs = 0.17). Itraconazole capsule reduced QALY in the model. For invasive aspergillosis prevention, posaconazole and voriconazole both resulted in better QALYs and life year savings compared with no prophylaxis. However, posaconazole prophylaxis was the only cost-saving option (976 USD per patient). CONCLUSION Posaconazole, itraconazole solution and voriconazole were all cost saving compared with no prophylaxis for overall IFI prophylaxis, with voriconazole being the most cost-effective option. Posaconazole and voriconazole were both cost effective for invasive aspergillosis prevention but only posaconazole was cost saving. A change in reimbursement policy for the use of AFT prophylaxis during intensive AML treatment could provide both clinical benefits to patients and substantial economic benefits to healthcare systems.
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Affiliation(s)
- T Pungprasert
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - W Phutthasakda
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - N Tantai
- Siriaj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Department of Pharmacy, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Maneeon
- Siriaj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Department of Pharmacy, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - V Nganthavee
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - K Atipas
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Tanpong
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Krithin
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Tanglitanon
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - W Jutidamrongphan
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - M Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - V Srinonprasert
- Siriaj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - P Phikulsod
- Division of Haematology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Kuthan R, Zaremba-Wróblewski GL, Ott F, Soltaninia D. Septic Obturation of a Knee Endoprosthesis Caused by Aspergillus clavatus. Pathogens 2023; 12:1270. [PMID: 37887786 PMCID: PMC10610210 DOI: 10.3390/pathogens12101270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
Aspergillus clavatus is a rare opportunistic fungal pathogen that can be isolated from various environmental sources, including soil and animal feces. Although infrequent, infections caused by A. clavatus can be severe in immunocompromised patients. Here, we present a case of a prosthetic joint infection (PJI) in a 74-year-old female patient caused by A. clavatus. The patient presented with left knee pain, and septic loosening of the left knee endoprosthesis was diagnosed. She underwent surgical revision with the implantation of an antibiotic spacer and microbiologic testing. The results came back positive for both Staphylococcus lugdunensis and A. clavatus (which is found in only a fraction of a percent of PJIs). She was treated with oral antimicrobials for 3 months postoperatively. This case report vividly illustrates a clinical scenario that underscores the significance of rigorous microbiologic testing procedures, accurate pathogen identification, unwavering vigilance in testing protocols, and a cautious approach that avoids succumbing to the seductive simplicity of Occam's razor.
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Affiliation(s)
- Robert Kuthan
- Chair and Department of Medical Microbiology, Medical University of Warsaw, 02-004 Warsaw, Poland;
- Student Scientific Club Microbiology Applied to Clinics and Real Life for Students (MACR-S) Affiliated to Chair and Department of Medical Microbiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Gabriel Lawrence Zaremba-Wróblewski
- Chair and Department of Medical Microbiology, Medical University of Warsaw, 02-004 Warsaw, Poland;
- Student Scientific Club Microbiology Applied to Clinics and Real Life for Students (MACR-S) Affiliated to Chair and Department of Medical Microbiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Flynn Ott
- Student Scientific Club Microbiology Applied to Clinics and Real Life for Students (MACR-S) Affiliated to Chair and Department of Medical Microbiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Dorsa Soltaninia
- Student Scientific Club Microbiology Applied to Clinics and Real Life for Students (MACR-S) Affiliated to Chair and Department of Medical Microbiology, Medical University of Warsaw, 02-091 Warsaw, Poland
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Shi C, Ye J, Xie Y, Dong R, Jin W, Wang L, Fang Y, Shan Q, Lin N. Cost-Effectiveness of Posaconazole vs. First-Generation Triazoles for the Prevention of Invasive Fungal Infections Among High-Risk Patients With Hematological Malignancies in China. Front Public Health 2022; 10:884846. [PMID: 35655452 PMCID: PMC9152267 DOI: 10.3389/fpubh.2022.884846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background Posaconazole is confirmed to be more effective for preventing invasive fungal infections (IFIs) than first-generation triazoles (fluconazole and itraconazole), but its economic value has not been comprehensively evaluated in China. This study compared the cost-effectiveness of these two antifungal prophylaxis regimens in hematological-malignancy patients at high risk for IFIs from the Chinese healthcare perspective. Methods A hybrid decision tree and Markov model were built using published data to estimate the total costs and quality-adjusted life-years (QALYs) of antifungal prophylaxis with posaconazole oral suspension and first-generation triazoles. Regimens with an incremental cost-effectiveness ratio (ICER) lower than the threshold of willingness to pay (WTP) were considered cost-effective. One-way and probabilistic sensitivity analyses were performed to assess model robustness. The regional imbalance of economic development and the tablet formulation of posaconazole were considered in the scenario analyses. Results In the base-case analysis, posaconazole oral suspension provided an additional 0.109 QALYs at an incremental cost of $954.7, yielding an ICER of $8,784.4/QALY, below the national WTP threshold of $31,315/QALY. One-way and probabilistic sensitivity analyses showed that the results were robust. Scenario analyses showed that the base-case ICER was consistently below the WTP thresholds of all 31 Chinese provinces, with the likelihood of posaconazole being cost-effectiveness ranging from 78.1 to 99.0%. When the posaconazole oral suspension was replaced by the tablet formulation, the ICER increased to $29,214.1/QALY, still below the national WTP threshold and WTP thresholds of 12 provinces. Conclusions Posaconazole oral suspension is a highly cost-effective regimen for preventing IFI in high-risk hematological-malignancy patients from the Chinese healthcare perspective. Posaconazole tablets may also be considered in some high-income regions of China.
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Affiliation(s)
- Changcheng Shi
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian Ye
- Department of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yaping Xie
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Rong Dong
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weizhong Jin
- Department of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Linling Wang
- Department of Pharmacy, Shaoxing Hospital of Traditional Chinese Medicine, Shaoxing, China
| | - Yingying Fang
- Department of Pharmacy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Qiyuan Shan
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Nengming Lin
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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MacIntyre AT, Hirst A, Duttagupta R, Hollemon D, Hong DK, Blauwkamp TA. Budget Impact of Microbial Cell-Free DNA Testing Using the Karius ® Test as an Alternative to Invasive Procedures in Immunocompromised Patients with Suspected Invasive Fungal Infections. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2021; 19:231-241. [PMID: 32944831 PMCID: PMC7497859 DOI: 10.1007/s40258-020-00611-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/08/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Invasive fungal infection is a major source of morbidity and mortality. The usage of microbial cell-free DNA for the detection and identification of invasive fungal infection has been considered as a potential alternative to invasive procedures allowing for rapid results. OBJECTIVE This analysis aimed to assess the budget implications of using the Karius® Test in patients suspected of invasive fungal infection in an average state in the USA from a healthcare payer perspective. METHODS The analysis used a decision tree to capture key stages of the patient pathway, from suspected invasive fungal infection to either receiving treatment for invasive fungal infection or being confirmed as having no invasive fungal infection. The analysis used published costs and resource use from a targeted review of the literature. Because of the paucity of published evidence on the reduction of diagnostic tests displaced by the Karius Test, the analysis used a 50% reduction in the use of bronchoscopy and/or bronchoalveolar lavage. The impact of this reduction was tested in a scenario analysis. RESULTS The results of the analysis show that the introduction of the Karius Test is associated with a cost saving of US$2277 per patient; when multiplied by the estimated number of cases per year, the cost saving is US$17,039,666. The scenario analysis showed that the Karius Test only had an incremental cost of US$87 per patient when there was no reduction in bronchoscopy and bronchoalveolar lavage. CONCLUSIONS The Karius Test may offer a valuable and timely option for the diagnosis of invasive fungal infection through its non-invasive approach and subsequent cost savings.
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Affiliation(s)
- Ann T MacIntyre
- Karius, Inc., 975 Island Drive, Suite 101, Redwood City, CA, 94065, USA.
| | | | - Radha Duttagupta
- Karius, Inc., 975 Island Drive, Suite 101, Redwood City, CA, 94065, USA
| | - Desiree Hollemon
- Karius, Inc., 975 Island Drive, Suite 101, Redwood City, CA, 94065, USA
| | - David K Hong
- Karius, Inc., 975 Island Drive, Suite 101, Redwood City, CA, 94065, USA
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Abstract
PURPOSE OF REVIEW Despite advances in therapy over the past decades, overall survival for children with acute myeloid leukemia (AML) has not exceeded 70%. In this review, we highlight recent insights into risk stratification for patients with pediatric AML and discuss data driving current and developing therapeutic approaches. RECENT FINDINGS Advances in cytogenetics and molecular profiling, as well as improvements in detection of minimal residual disease after induction therapy, have informed risk stratification, which now relies heavily on these elements. The treatment of childhood AML continues to be based primarily on intensive, conventional chemotherapy. However, recent trials focus on limiting treatment-related toxicity through the identification of low-risk subsets who can safely receive fewer cycles of chemotherapy, allocation of hematopoietic stem-cell transplant to only high-risk patients and optimization of infectious and cardioprotective supportive care. SUMMARY Further incorporation of genomic and molecular data in pediatric AML will allow for additional refinements in risk stratification to enable the tailoring of treatment intensity. These data will also dictate the incorporation of molecularly targeted therapeutics into frontline treatment in the hope of improving survival while decreasing treatment-related toxicity.
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Tuon FF, Florencio KL, Rocha JL. Burden of acute kidney injury in HIV patients under deoxycholate amphotericin B therapy for cryptococcal meningitis and cost-minimization analysis of amphotericin B lipid complex. Med Mycol 2019; 57:265-269. [PMID: 29762761 DOI: 10.1093/mmy/myy025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 02/13/2018] [Accepted: 04/07/2018] [Indexed: 01/21/2023] Open
Abstract
Deoxycholate amphotericin B (d-AMB) has a higher rate of acute kidney injury (AKI) in comparison of lipid formulations. However, lipid amphotericin B has high costs in developing countries. The aim of this study is to assemble a model of cost-minimization of amphotericin B lipid complex (ABLC) in patients with cryptococcal meningitis. This is a retrospective study done in a cohort of patients with cryptococcal meningitis to study the economic impact of its use in developing countries. Cost analysis were based on direct cost of different antifungal therapies, chronic dialysis after discharge, and survival of patients based on a retrospective cohort of 102 patients infected with human immunodeficiency virus with confirmed diagnosis of cryptococcal meningitis. From 102 patients treated with d-AMB, 60.78% developed any grade of AKI and 10.78% developed AKI demanding hemodialysis. The percentage of patients with meningeal cryptococcosis treated with d-AMB that requeired chronic HD was 2.39%. The same model was performed for patient that would be treated with ABLC, which resulted in 0.20% of patients demanding chronic HD due to its lower nephrotoxicity. When the model is applied in 100 patients, the total costs with d-AMB would be US$ 184,543 and with ABLC would be US$ 1,640,109 in 5 years. Treatment with ABLC would be cost saving in comparison to d-AMB treatment, if early switch of treatment occurred in patients presenting AKI. The change should be as soon as possible to avoid further complication, like dialysis, which is associated with a lower life expectancy.
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Affiliation(s)
- Felipe Francisco Tuon
- Department of Medicine, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | - Khaiany Lino Florencio
- Division of Infectious Diseases, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Jaime L Rocha
- Department of Medicine, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
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Tuon FFB, Lino Florencio K, da Cunha CA, Lopes Rocha JL. Cost-effectiveness of posaconazole in private and public Brazilian hospitals. Rev Iberoam Micol 2018; 35:63-67. [PMID: 29605496 DOI: 10.1016/j.riam.2017.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/22/2017] [Accepted: 09/05/2017] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Posaconazole is used for the prophylaxis of invasive fungal disease (IFD). Previous studies have shown it to be cost-effective compared to fluconazole/itraconazole. However, posaconazole has never been economically evaluated in developing countries. AIMS The aim of the present study was to perform a cost-effectiveness analysis of posaconazole compared to fluconazole in public (SUS) and private hospitals (PHS) in Brazil. METHODS A cost-effectiveness simulation was conducted on the basis of a pivotal study on the use of posaconazole in acute myeloid leukemia (AML) patients, adjusting the costs to Brazilian data. RESULTS A pharmacoeconomic analysis was performed on a hypothetical sample of 100 patients in each drug group. The total cost of posaconazole use alone was USD$ 220,656.31, whereas that for fluconazole was USD$ 83,875.00. Our results showed that patients with IFD remain hospitalized for an additional 12 days, at an average cost of USD$ 850.85 per patient per day. The total money spent by PHS for 100 patients for 100 days was USD$ 342,318.00 for the posaconazole group and USD$ 302,039.00 for the fluconazole group. An analysis of sensitivity (10%) revealed no intergroup difference. CONCLUSIONS In Brazil posaconazole is cost-effective, and should be considered for the prophylaxis of patients with AMD/myelodysplasia (AML/MDS) undergoing chemotherapy.
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Affiliation(s)
- Felipe F B Tuon
- Department of Medicine, School of Health and Biosciences, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil.
| | - Khaiany Lino Florencio
- Department of Medicine, School of Health and Biosciences, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | - Clóvis Arns da Cunha
- Department of Health Community, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Jaime Luis Lopes Rocha
- Department of Medicine, School of Health and Biosciences, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil; Unimed Curitiba, Curitiba, PR, Brazil
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Fluconazole versus mould-active triazoles for primary antifungal prophylaxis in adult patients with acute lymphoblastic leukemia: clinical outcome and cost-effectiveness analysis. Int J Hematol 2017; 107:235-243. [DOI: 10.1007/s12185-017-2342-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 09/26/2017] [Accepted: 09/29/2017] [Indexed: 10/18/2022]
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Tuon FF, Florencio KL, Rocha JL, Magalhaes FB. Long-term cost-effectiveness of lipid formulations of amphotericin B in the empirical therapy of invasive mycosis in a developing country. Rev Iberoam Micol 2017; 34:247-248. [DOI: 10.1016/j.riam.2017.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 01/20/2017] [Accepted: 03/10/2017] [Indexed: 10/19/2022] Open
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Cost-Effectiveness of Posaconazole Tablets for Invasive Fungal Infections Prevention in Acute Myelogenous Leukemia or Myelodysplastic Syndrome Patients in Spain. Adv Ther 2017; 34:2104-2119. [PMID: 28808915 PMCID: PMC5599452 DOI: 10.1007/s12325-017-0600-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Indexed: 01/29/2023]
Abstract
Introduction Posaconazole is superior to fluconazole (FLU) and itraconazole (ITRA) in the prevention of invasive fungal diseases (IFDs) in neutropenic patients with acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS). A new tablet formulation of posaconazole with improved pharmacokinetic and pharmacodynamic properties compared to posaconazole oral solution has recently been approved. The objective of this study is to estimate the cost-effectiveness of the newly developed posaconazole tablets versus FLU oral suspension or ITRA oral solution for preventing IFDs in high-risk neutropenic patients with AML or MDS and from the perspective of the Spanish National Health System (NHS). Methods A previously validated economic model was used. The probabilities of experiencing an IFD, an IFD-related death or death from other causes over 100 days were based on clinical trial data and input into a decision tree. Surviving patients were entered into a Markov model to calculate total costs, number of IFDs and number of life-years gained per patient over a lifetime horizon in each disease and treatment group. Two health states, alive and dead, were considered. Health effects were discounted using a rate of 3%. Univariate and probabilistic sensitivity analyses were conducted. Results During the first 100 days, posaconazole tablets were associated with a lower risk of IFDs (0.046 vs. 0.111), longer life expectancy (2.92 vs. 2.69 years) and lower total costs (€5906.06 vs. €7847.20 per patient) over the patients’ lifetimes compared to FLU or ITRA treatments. Thus, posaconazole tablets were more effective and less costly than FLU or ITRA. Probabilistic sensitivity analysis indicated that there was a 79.9% probability of posaconazole tablets being cost-saving compared to FLU or ITRA. Conclusion From the Spanish NHS perspective, posaconazole tablets are cost-effective compared to FLU or ITRA in AML or MSD patients with chemotherapy-induced neutropenia and at high risk for IFDs. Funding MSD Sharp & Dohme.
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Primary antifungal prophylaxis during curative-intent therapy for acute myeloid leukemia. Blood 2015; 126:2790-7. [PMID: 26504183 DOI: 10.1182/blood-2015-07-627323] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/21/2015] [Indexed: 11/20/2022] Open
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Soysal A. Prevention of invasive fungal infections in immunocompromised patients: the role of delayed-release posaconazole. Infect Drug Resist 2015; 8:321-31. [PMID: 26392781 PMCID: PMC4573198 DOI: 10.2147/idr.s65592] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Posaconazole is a triazole antifungal agent that has broad-spectrum activity against many yeasts and filamentous fungi, including Candida species, Cryptococcus neoformans, Aspergillus species, and Zygomycetes. This drug has been approved for the prevention of invasive fungal infections in patients with neutropenia and for the treatment of invasive fungal infections in hematopoietic stem cell transplant recipients with graft-versus-host disease. Studies on the clinical efficacy, safety, tolerability, and cost-effectiveness of posaconazole therapy were performed using the oral suspension form of the drug. Pharmacokinetic studies have found that the oral suspension form of posaconazole has problemeatic bioavailability: its absorption is affected by concomitant medication and food. This article discusses the pharmacokinetic properties of the newly developed posaconazole delayed-release tablet formulation and reviews the efficacy, safety, and cost-effectiveness of both the oral suspension and the new tablet formulation. In conclusion, the posaconazole tablet formulation has better systemic bioavailability, thereby enabling once-daily administration and better absorption in the presence of concomitant medication and food. However, well-designed clinical studies are needed to evaluate the use of the tablet formulation in real-life settings.
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Affiliation(s)
- Ahmet Soysal
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Marmara University, Istanbul, Turkey
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Cho SY, Lee DG, Choi JK, Lee HJ, Kim SH, Park SH, Choi SM, Choi JH, Yoo JH, Kim YJ, Kim HJ, Min WS, Back H, Kang S, Lee EK. Cost-benefit Analysis of Posaconazole Versus Fluconazole or Itraconazole as a Primary Antifungal Prophylaxis in High-risk Hematologic Patients: A Propensity Score-matched Analysis. Clin Ther 2015; 37:2019-27. [PMID: 26188835 DOI: 10.1016/j.clinthera.2015.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 06/17/2015] [Accepted: 06/19/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Posaconazole is effective for the prophylaxis of invasive fungal infections (IFIs) in patients with acute myeloid leukemia or myelodysplastic syndrome during remission induction chemotherapy. However, a cost-benefit analysis of posaconazole versus fluconazole or itraconazole has not been conducted in Korea. METHODS We retrospectively reviewed data for all consecutive patients who received primary antifungal prophylaxis during remission induction chemotherapy in our acute myeloid leukemia/myelodysplastic syndrome cohort from December 2010 to November 2013. Patient characteristics and factors known as a risk of IFI were matched with propensity score analysis. We evaluated the medical cost according to the prophylactic antifungal agents (posaconazole vs fluconazole/itraconazole), the development of breakthrough IFIs, and survival status after propensity score matching in a 1:1 ratio. FINDINGS Of the 419 baseline patients, 100 patients in each group were analyzed after matching. A significant decrease was found in the development of breakthrough proven or probable IFIs (3.0% vs 14.0%; P = 0.009) and the rate of empirical antifungal therapy (EAFT) (12.0% vs 46.0%; P < 0.001) in the posaconazole group. Total in-hospital medical costs per patient were not statistically different between posaconazole and fluconazole/itraconazole prophylaxis. However, the daily medical cost was lower for posaconazole prophylaxis, resulting in a total daily cost savings of $72 (₩79,458) per patient (P = 0.002). In the cases of breakthrough proven/probable IFIs, EAFT, and in-hospital deaths, the total medical costs per patient were significantly higher than in nonproven/probable IFIs, non-EAFT, and in-hospital survivors, as much as $7,916 (₩8,700,758), $4605 (₩5,062,529), and $11,134 (₩12,238,422), respectively. Costs for the antifungal agent used in targeted or empirical therapy were lower in the posaconazole group, resulting in a savings of $697 (₩766,347) per patient (P < 0.001). IMPLICATIONS Posaconazole appears to be cost beneficial for primary antifungal prophylaxis in high-risk patients with hematologic malignancy, at a single center, in Korea. Cost-benefit is closely related with clinical outcomes, including breakthrough IFI development, EAFT, and survival status.
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Affiliation(s)
- Sung-Yeon Cho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Vaccine Bio Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Vaccine Bio Research Institute, The Catholic University of Korea, Seoul, Republic of Korea; The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Jae-Ki Choi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Vaccine Bio Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyo-Jin Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Vaccine Bio Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Si-Hyun Kim
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Vaccine Bio Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sun-Hee Park
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Vaccine Bio Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Su-Mi Choi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Vaccine Bio Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung-Hyun Choi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Vaccine Bio Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin-Hong Yoo
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Vaccine Bio Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoo-Jin Kim
- The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hee-Je Kim
- The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Woo-Sung Min
- The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Heejung Back
- Market Access, Merck Sharp & Dohme, Seoul, Republic of Korea
| | - Sukhyun Kang
- Market Access, Merck Sharp & Dohme, Seoul, Republic of Korea; Pharmaceutical Policy & Outcomes Research, School of Pharmacy, Sungkyunkwan University, Seoul, Republic of Korea
| | - Eui-Kyung Lee
- Pharmaceutical Policy & Outcomes Research, School of Pharmacy, Sungkyunkwan University, Seoul, Republic of Korea
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Sung AH, Marcella SW, Xie Y. An update to the cost-effectiveness of posaconazole vs fluconazole or itraconazole in the prevention of invasive fungal disease among neutropenic patients in the United States. J Med Econ 2015; 18:341-8. [PMID: 25524741 DOI: 10.3111/13696998.2014.1000460] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Posaconazole has shown superior clinical efficacy in the prevention of invasive fungal disease (IFD) among neutropenic patients as well as cost-effectiveness in the US healthcare setting vs fluconazole or itraconazole (FLU/ITRA) based on oral suspension formulations of each therapy. This study aims to provide an update on the cost-effectiveness of posaconazole in the current US healthcare setting to reflect bioequivalent tablet formulations of posaconazole and fluconazole, as well as changes in healthcare and drug costs. METHODS An existing model was used to assess the cost-effectiveness of posaconazole vs FLU/ITRA in the prevention of IFD among patients with acute myelogenous leukemia (AML) or myelodysplastic syndrome (MDS) and chemotherapy-induced neutropenia. Drug efficacy, mortality related to IFD, and death from other causes were estimated for tablet formulations using data from a randomized clinical trial of oral suspensions based on bioequivalence. IFD treatment costs were updated using the average inflation rate over 8 years (2006-2014) and drug costs were based on 2014 Analysource data. RESULTS Trial data show a lower IFD probability over 100 days of follow-up with posaconazole compared to standard azole therapy (0.05 vs 0.11). The treatment duration on posaconazole is 29 days compared to 24 days for FLU and 29 days for ITRA. The average cost of prophylaxis is higher in the posaconazole group compared to FLU/ITRA ($4673 vs $353); however, the costs associated with treating the IFD are lower in the posaconazole group compared to FLU/ITRA ($2205 vs $5303). The incremental cost effectiveness ratio of IFD avoided for posaconazole is $18,898 vs FLU/ITRA. CONCLUSIONS In the current healthcare cost environment where both drug costs and overall IFD treatment costs have increased since 2007, posaconazole tablets are a cost-effective alternative to fluconazole or itraconazole in the prevention of IFD among neutropenic patients with AML and MDS in the US.
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Lundberg J, Höglund M, Björkholm M, Åkerborg Ö. Economic evaluation of posaconazole versus fluconazole or itraconazole in the prevention of invasive fungal infection in high-risk neutropenic patients in Sweden. Clin Drug Investig 2015; 34:483-9. [PMID: 24820968 DOI: 10.1007/s40261-014-0199-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In patients undergoing induction chemotherapy for acute myeloid leukemia (AML) or myelodysplastic syndromes (MDS), posaconazole has been proven more effective in the prevention of invasive fungal infection (IFI) than fluconazole or itraconazole (standard azoles) The current analysis seeks to estimate the cost effectiveness of prophylactic posaconazole compared with standard azoles in AML or MDS patients with severe chemotherapy-induced neutropenia in Sweden. METHODS A decision-analytic model was used to estimate life expectancy, costs, and quality-adjusted life-years (QALYs). Efficacy data were derived from a phase III clinical trial. Life expectancy and quality of life data were collected from the literature. A modified Delphi method was used to gather expert opinion on resource use for an IFI. Unit costs were captured from hospital and pharmacy pricelists. A probabilistic sensitivity analysis (PSA) was used to investigate the impact of uncertainty in the model parameters on the cost-effectiveness results. RESULTS The estimated mean direct cost per patient with posaconazole prophylaxis was 46,893 Swedish kronor (SEK) (€5,387) and SEK50,017 (€5,746) with standard azoles. Prophylaxis with posaconazole resulted in 0.075 QALYs gained compared with standard azoles. At a cost-effectiveness threshold of SEK500,000/QALY the PSA demonstrated a more than 95 % probability that posaconazole is cost effective versus standard azoles for the prevention of IFI in high-risk neutropenic patients in Sweden. CONCLUSION Given the assumptions, methods, and data used, posaconazole is expected to be cost effective compared with standard azoles when used as antifungal prophylaxis in AML or MDS patients with chemotherapy-induced prolonged neutropenia in Sweden.
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Affiliation(s)
- Johan Lundberg
- Outcomes Research, MSD Sweden (AB), Rotebersvagen 3, 19207, Sollentuna, Sweden,
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Maertens J, Lyon S. Meeting the challenge of invasive fungal infections: part 2. Future Microbiol 2014; 8:1245-7. [PMID: 24059915 DOI: 10.2217/fmb.13.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The 23rd European Congress of Clinical Microbiology and Infectious Diseases 2013 Berlin, Germany, 27-30 April 2013. This second and final installment of the report on the 23rd European Congress of Clinical Microbiology and Infectious Diseases follows on from Part 1, published in the September 2013 (volume 8, issue 9) issue of Future Microbiology. Invasive fungal infections (IFIs) are a well-recognized complication in immunocompromised patients, with neutropenic patients with leukemia and hematopoietic stem cell transplant recipients at especially high risk. Early diagnosis of IFIs is essential, since delaying the initiation of adequate antifungal therapy increases the risk of death. The rapid diagnosis, and effective treatment and prophylaxis of IFIs were among the topics discussed during the 2013 conference of the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID 2013).
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Affiliation(s)
- Johan Maertens
- Department of Haematology, Universitaire Ziekenhuizen Campus Gasthuisberg, KU Leuven, Leuven, Belgium.
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Pagano L, Caira M. The role of primary antifungal prophylaxis in patients with haematological malignancies. Clin Microbiol Infect 2014; 20 Suppl 6:19-26. [PMID: 24372659 DOI: 10.1111/1469-0691.12464] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 11/18/2013] [Accepted: 11/18/2013] [Indexed: 11/30/2022]
Abstract
Invasive fungal infections (IFIs) represent important complications in patients with haematological malignancies. Chemoprevention of IFIs may play an important role in this setting, but in the past decades the majority of antifungal drugs utilized demonstrated poor efficacy, particularly in the prevention of invasive aspergillosis. The new triazoles are very useful antifungal drugs, more suitable for prophylaxis of IFIs than amphotericin B and echinocandins. In this review, the main clinical data about antifungal prophylaxis with fluconazole, itraconazole, voriconazole and posaconazole are analysed. At present, posaconazole appears to be the most efficacious azole in antifungal prophylaxis, particularly in patients with acute myeloid leukaemia.
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Affiliation(s)
- L Pagano
- Istituto di Ematologia, Università Cattolica del Sacro Cuore, Rome, Italy
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