A 1-year prospective cost-effectiveness analysis of roflumilast for the treatment of patients with severe chronic obstructive pulmonary disease

The Saudi Thoracic Society Evidence-based guidelines for the diagnosis and management of chronic obstructive pulmonary disease

The Saudi Thoracic Society (STS) developed an updated evidence-based guideline for diagnosing and managing chronic obstructive pulmonary disease (COPD) in Saudi Arabia. This guideline aims to provide a comprehensive and unbiased review of current evidence for assessing, diagnosing, and treating COPD. While epidemiological data on COPD in Saudi Arabia are limited, the STS panel believes that the prevalence is increasing due to rising rates of tobacco smoking. The key objectives of the guidelines are to facilitate accurate diagnosis of COPD, identify the risk for COPD exacerbations, and provide recommendations for relieving and reducing COPD symptoms in stable patients and during exacerbations. A unique aspect of this guideline is its simplified, practical approach to classifying patients into three classes based on symptom severity using the COPD Assessment Test and the risk of exacerbations and hospitalizations. The guideline provides the reader with an executive summary of recommended COPD treatments based on the best available evidence and also addresses other major aspects of COPD management and comorbidities. This guideline is primarily intended for use by internists and general practitioners in Saudi Arabia.

Phosphodiesterase-4 inhibitors for chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with cough, sputum production or dyspnoea, and a reduction in lung function, quality of life, and life expectancy. Apart from smoking cessation, no other treatments that slow lung function decline are available. Roflumilast and cilomilast are oral phosphodiesterase-4 (PDE₄) inhibitors proposed to reduce the airway inflammation and bronchoconstriction seen in COPD. This Cochrane Review was first published in 2011, and was updated in 2017 and 2020.

OBJECTIVES

To evaluate the efficacy and safety of oral PDE₄ inhibitors for management of stable COPD.

SEARCH METHODS

We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register (date of last search 9 March 2020). We found other trials at web-based clinical trials registers.

SELECTION CRITERIA

We included RCTs if they compared oral PDE₄ inhibitors with placebo in people with COPD. We allowed co-administration of standard COPD therapy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Two independent review authors selected trials for inclusion, extracted data, and assessed risk of bias. We resolved discrepancies by involving a third review author. We assessed our confidence in the evidence by using GRADE recommendations. Primary outcomes were change in lung function (minimally important difference (MID) = 100 mL) and quality of life (scale 0 to 100; higher score indicates more limitations).

MAIN RESULTS

We found 42 RCTs that met the inclusion criteria and were included in the analyses for roflumilast (28 trials with 18,046 participants) or cilomilast (14 trials with 6457 participants) or tetomilast (1 trial with 84 participants), with a duration between six weeks and one year or longer. These trials included people across international study centres with moderate to very severe COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades II to IV), with mean age of 64 years. We judged risks of selection bias, performance bias, and attrition bias as low overall amongst the 39 published and unpublished trials. Lung function Treatment with a PDE₄ inhibitor was associated with a small, clinically insignificant improvement in forced expiratory volume in one second (FEV₁) over a mean of 40 weeks compared with placebo (mean difference (MD) 49.33 mL, 95% confidence interval (CI) 44.17 to 54.49; participants = 20,815; studies = 29; moderate-certainty evidence). Forced vital capacity (FVC) and peak expiratory flow (PEF) were also improved over 40 weeks (FVC: MD 86.98 mL, 95% CI 74.65 to 99.31; participants = 22,108; studies = 17; high-certainty evidence; PEF: MD 6.54 L/min, 95% CI 3.95 to 9.13; participants = 4245; studies = 6; low-certainty evidence). Quality of life Trials reported improvements in quality of life over a mean of 33 weeks (St George's Respiratory Questionnaire (SGRQ) MD -1.06 units, 95% CI -1.68 to -0.43; participants = 7645 ; moderate-certainty evidence). Incidence of exacerbations Treatment with a PDE₄ inhibitor was associated with a reduced likelihood of COPD exacerbation over a mean of 40 weeks (odds ratio (OR) 0.78, 95% CI 0.73 to 0.84; participants = 20,382; studies = 27; high-certainty evidence), that is, for every 100 people treated with PDE₄ inhibitors, five more remained exacerbation-free during the study period compared with those given placebo (number needed to treat for an additional beneficial outcome (NNTB) 20, 95% CI 16 to 27). No change in COPD-related symptoms nor in exercise tolerance was found. Adverse events More participants in the treatment groups experienced an adverse effect compared with control participants over a mean of 39 weeks (OR 1.30, 95% CI 1.22 to 1.38; participants = 21,310; studies = 30; low-certainty evidence). Participants experienced a range of gastrointestinal symptoms such as diarrhoea, nausea, vomiting, or dyspepsia. Diarrhoea was more commonly reported with PDE₄ inhibitor treatment (OR 3.20, 95% CI 2.74 to 3.50; participants = 20,623; studies = 29; high-certainty evidence), that is, for every 100 people treated with PDE₄ inhibitors, seven more suffered from diarrhoea during the study period compared with those given placebo (number needed to treat for an additional harmful outcome (NNTH) 15, 95% CI 13 to 17). The likelihood of psychiatric adverse events was higher with roflumilast 500 µg than with placebo (OR 2.13, 95% CI 1.79 to 2.54; participants = 11,168; studies = 15 (COPD pool data); moderate-certainty evidence). Roflumilast in particular was associated with weight loss during the trial period and with an increase in insomnia and depressive mood symptoms. Participants treated with PDE₄ inhibitors were more likely to withdraw from trial participation; on average, 14% in the treatment groups withdrew compared with 8% in the control groups. Mortality No effect on mortality was found (OR 0.98, 95% CI 0.77 to 1.24; participants = 19,786; studies = 27; moderate-certainty evidence), although mortality was a rare event during these trials.

AUTHORS' CONCLUSIONS

For this current update, five new studies from the 2020 search contributed to existing findings but made little impact on outcomes described in earlier versions of this review. PDE₄ inhibitors offered a small benefit over placebo in improving lung function and reducing the likelihood of exacerbations in people with COPD; however, they had little impact on quality of life or on symptoms. Gastrointestinal adverse effects and weight loss were common, and the likelihood of psychiatric symptoms was higher, with roflumilast 500 µg. The findings of this review provide cautious support for the use of PDE₄ inhibitors in COPD. In accordance with GOLD 2020 guidelines, they may have a place as add-on therapy for a subgroup of people with persistent symptoms or exacerbations despite optimal COPD management (e.g. people whose condition is not controlled by fixed-dose long-acting beta₂-agonist (LABA) and inhaled corticosteroid (ICS) combinations). More longer-term trials are needed to determine whether or not PDE₄ inhibitors modify FEV₁ decline, hospitalisation, or mortality in COPD.

Phosphodiesterase 4 inhibitors for chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with cough, sputum production or dyspnoea and a reduction in lung function, quality of life and life expectancy. Apart from smoking cessation, there are no other treatments that slow lung function decline. Roflumilast and cilomilast are oral phosphodiesterase 4 (PDE4) inhibitors proposed to reduce the airway inflammation and bronchoconstriction seen in COPD. This is an update of a Cochrane review first published in 2011 and updated in 2013.

OBJECTIVES

To evaluate the efficacy and safety of oral PDE4 inhibitors in the management of stable COPD.

SEARCH METHODS

We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register (date of last search October 2016). We found other trials from web-based clinical trials registers.

SELECTION CRITERIA

We included RCTs if they compared oral PDE4 inhibitors with placebo in people with COPD. We allowed co-administration of standard COPD therapy.

DATA COLLECTION AND ANALYSIS

One review author extracted data and a second review author checked the data. We reported pooled data in Review Manager as mean differences (MD), standardised mean differences (SMD) or odds ratios (OR). We converted the odds ratios into absolute treatment effects in a 'Summary of findings' table.

MAIN RESULTS

Thirty-four separate RCTs studying roflumilast (20 trials with 17,627 participants) or cilomilast (14 trials with 6457 participants) met the inclusion criteria, with a duration of between six weeks and one year. These included people across international study centres with moderate to very severe COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades II-IV), with a mean age of 64 years.We considered that the methodological quality of the 34 published and unpublished trials was acceptable overall. Treatment with a PDE4 inhibitor was associated with a significant improvement in forced expiratory volume in one second (FEV1) over the trial period compared with placebo (MD 51.53 mL, 95% confidence interval (CI) 43.17 to 59.90, 27 trials with 20,585 participants, moderate-quality evidence due to moderate levels of heterogeneity and risk of reporting bias). There were small improvements in quality of life (St George's Respiratory Questionnaire (SGRQ), MD -1.06 units, 95% CI -1.68 to -0.43, 11 trials with 7645 participants, moderate-quality evidence due to moderate levels of heterogeneity and risk of reporting bias) and COPD-related symptoms, but no significant change in exercise tolerance. Treatment with a PDE4 inhibitor was associated with a reduced likelihood of COPD exacerbation (OR 0.78, 95% CI 0.73 to 0.83; 23 trials with 19,948 participants, high-quality evidence). For every 100 people treated with PDE4 inhibitors, five more remained exacerbation-free during the study period compared with placebo (number needed to treat for an additional beneficial outcome (NNTB) 20, 95% CI 16 to 26). More participants in the treatment groups experienced non-serious adverse events compared with controls, particularly a range of gastrointestinal symptoms such as diarrhoea, nausea, vomiting or dyspepsia. For every 100 people treated with PDE4 inhibitors, seven more suffered from diarrhoea during the study period compared with placebo (number needed to treat for an additional harmful outcome (NNTH) 15, 95% CI 13 to 17). Roflumilast in particular was associated with weight loss during the trial period and an increase in insomnia and depressive mood symptoms. There was no significant effect of treatment on non-fatal serious adverse events (OR 0.99, 95% CI 0.91 to 1.07) or mortality (OR 0.97, 95% CI 0.76 to 1.23), although mortality was a rare event during the trials. Participants treated with PDE4 inhibitors were more likely to withdraw from the trials because of adverse effects; on average 14% in the treatment groups withdrew compared with 8% in the control groups.

AUTHORS' CONCLUSIONS

In people with COPD, PDE4 inhibitors offered benefit over placebo in improving lung function and reducing the likelihood of exacerbations; however, they had little impact on quality of life or symptoms. Gastrointestinal adverse effects and weight loss were common, and safety data submitted to the US Food and Drug Administration (FDA) have raised concerns over psychiatric adverse events with roflumilast. The findings of this review give cautious support to the use of PDE4 inhibitors in COPD. They may be best used as add-on therapy in a subgroup of people with persistent symptoms or exacerbations despite optimal COPD management. This is in accordance with the GOLD 2017 guidelines. Longer-term trials are needed to determine whether or not PDE4 inhibitors modify FEV1 decline, hospitalisation or mortality in COPD.

Systematic review of models used in economic analyses in moderate-to-severe asthma and COPD

BACKGROUND

Respiratory diseases exert a substantial burden on society, with newer drugs increasingly adding to the burden. Economic models are often used, but seldom reviewed.

PURPOSE

To summarize economic models used in economic analyses of drugs treating moderate-to-severe/very severe asthma or chronic obstructive pulmonary disease (COPD).

METHODS

This study searched Medline and Embase from inception to the end of February 2015 for cost-effectiveness/utility analyses that examined at least one drug against placebo, another drug, or other standard therapy in asthma or COPD. Two reviewers independently searched and extracted data with differences adjudicated via consensus discussion. Data extracted included model used and its qualities, validation methods, treatments compared, disease severity, analytic perspective, time horizon, data collection (pro- or retrospective), input rates and sources, costs and sources, planned sensitivity analyses, criteria for cost-effectiveness, reported outcomes, and sponsor.

RESULTS

This study analyzed 53 articles; 14 (25%) on asthma and 39 (75%) COPD. Markov models were commonly used for both asthma and COPD-related economic evaluations. Relatively few studies validated their model. For asthma-related studies, 10 examined inhaled corticosteroids and nine studied omalizumab. Placebo or standard therapy was the comparison in 11 studies and active drugs in the remainder.

CONCLUSIONS

Few studies include validation of their models. Furthermore, controversy concerning some results was uncovered in this study, which needs to be avoided in the future.

Estimating productivity costs using the friction cost approach in practice: a systematic review

INTRODUCTION

The choice of the most appropriate approach to valuing productivity loss has received much debate in the literature. The friction cost approach has been proposed as a more appropriate alternative to the human capital approach when valuing productivity loss, although its application remains limited. This study reviews application of the friction cost approach in health economic studies and examines how its use varies in practice across different country settings.

METHODS

A systematic review was performed to identify economic evaluation studies that have estimated productivity costs using the friction cost approach and published in English from 1996 to 2013. A standard template was developed and used to extract information from studies meeting the inclusion criteria.

RESULTS

The search yielded 46 studies from 12 countries. Of these, 28 were from the Netherlands. Thirty-five studies reported the length of friction period used, with only 16 stating explicitly the source of the friction period. Nine studies reported the elasticity correction factor used. The reported friction cost approach methods used to derive productivity costs varied in quality across studies from different countries.

CONCLUSIONS

Few health economic studies have estimated productivity costs using the friction cost approach. The estimation and reporting of productivity costs using this method appears to differ in quality by country. The review reveals gaps and lack of clarity in reporting of methods for friction cost evaluation. Generating reporting guidelines and country-specific parameters for the friction cost approach is recommended if increased application and accuracy of the method is to be realized.

Economic Evaluation alongside Multinational Studies: A Systematic Review of Empirical Studies

Purpose of the study

This study seeks to explore methods for conducting economic evaluations alongside multinational trials by conducting a systematic review of the methods used in practice and the challenges that are typically faced by the researchers who conducted the economic evaluations.

Methods

A review was conducted for the period 2002 to 2012, with potentially relevant articles identified by searching the Medline, Embase and NHS EED databases. Studies were included if they were full economic evaluations conducted alongside a multinational trial.

Results

A total of 44 studies out of a possible 2667 met the inclusion criteria. Methods used for the analyses varied between studies, indicating a lack of consensus on how economic evaluation alongside multinational studies should be carried out. The most common challenge appeared to be related to addressing differences between countries, which potentially hinders the generalisability and transferability of results. Other challenges reported included inadequate sample sizes and choosing cost-effectiveness thresholds.

Conclusions

It is recommended that additional guidelines be developed to aid researchers in this area and that these be based on an understanding of the challenges associated with multinational trials and the strengths and limitations of alternative approaches. Guidelines should focus on ensuring that results will aid decision makers in their individual countries.

Impact of roflumilast on exacerbations of COPD, health care utilization, and costs in a predominantly elderly Medicare Advantage population

Background

Chronic obstructive pulmonary disease (COPD) exacerbations are associated with declining lung function and health-related quality of life, and increased hospitalization and mortality. Clinical trials often poorly represent the elderly and thus have only partial applicability to their clinical care.

Objective

To compare exacerbations, COPD-related health care utilization (HCU), and costs in a predominantly elderly Medicare COPD population initiated on roflumilast versus those not initiated on roflumilast.

Methods

Deidentified administrative claims data from a large, national payer were utilized. Medicare patients aged 40–89 years with at least one COPD diagnosis from May 1, 2010 to December 31, 2012 were included. Members with at least one roflumilast pharmacy claim (index) were assigned to the roflumilast group and those without were assigned to the non-roflumilast group. Proxy index dates for the non-roflumilast group were randomly assigned for similar distribution of all patients’ time at risk. Subjects with at least one pre-index COPD exacerbation had to be continuously enrolled for ≥365 days pre-index and post-index. Unadjusted and adjusted difference-in-difference (DID) analyses contrasted pre-index with post-index changes in exacerbations, HCU, and costs of roflumilast treatment compared with non-roflumilast treatment.

Results

A total of 500 roflumilast and 60,145 non-roflumilast patients were included (mean age 69.7 and 72.3 years, respectively; P<0.0001). Unadjusted DID favored roflumilast for all exacerbations, with greater pre-index to post-index reductions in mean per 30-day COPD-related hospitalizations (−0.0182 versus −0.0013, P=0.009), outpatient visits (−0.2500 versus −0.0606, P<0.0001), and COPD-related inpatient costs (−US$141 versus −US$11, P=0.0346) and outpatient costs (−US$31 versus −US$4, P<0.0001). Multivariate analyses identified significantly improved pre-index to post-index COPD-related total costs (P=0.0005) and total exacerbations (P<0.0001) for the roflumilast group versus non-roflumilast group.

Conclusion

In a predominantly elderly Medicare COPD population, newly initiated roflumilast patients displayed similar or significantly better unadjusted reductions in all exacerbation-related, COPD-related HCU-related, and COPD-related costs outcomes compared with non-roflumilast patients. These analyses also suggest better adjusted COPD-related costs and total exacerbations for roflumilast-initiated patients.

Vulnerable COPD patients with comorbidities: the role of roflumilast

Roflumilast is a selective phosphodiesterase-4 (PDE-4) inhibitor that was approved by the US Food and Drug Administration in February 2011 for the management of chronic obstructive pulmonary disease (COPD). Literature was retrieved through PubMed using the terms "roflumilast" and "COPD". Reference citations from publications identified were also reviewed. All articles published in English using the terms "roflumilast" and "COPD" were retrieved. For evaluation of clinical efficacy, published Phase III studies and pooled analyses of Phase III trials were included. In seven published Phase III trials, roflumilast at 500 μg daily showed improvements in lung function as measured by pre- and post-bronchodilator forced expiratory volume in 1 second. Roflumilast appears to be useful in vulnerable patients who are at high risk for exacerbations. Roflumilast was found to be effective when administered alone and with concomitant long-acting bronchodilator therapy in the Caucasian and Asian population. Patients with severe-to-very severe COPD, chronic bronchitis, and frequent history of exacerbations derived the greatest benefit with roflumilast. Compared to the standard of care therapies, roflumilast is more cost-prohibitive. Roflumilast was well tolerated, with the most common adverse events observed in clinical trials being diarrhea, nausea, and headache. Weight loss and increased risk of psychiatric events have also been observed with roflumilast in clinical trials. Roflumilast is a safe and effective option for the treatment of COPD.

Roflumilast in the management of chronic obstructive pulmonary disease

PURPOSE

The pharmacology, pharmacokinetics, efficacy, and safety of roflumilast-the first in a new class of agents for managing chronic obstructive pulmonary disease (COPD)-are reviewed.

SUMMARY

Roflumilast (Daliresp, Forest Pharmaceuticals) is an oral phosphodiesterase-4 (PDE-4) inhibitor that targets inflammatory cells involved in triggering COPD exacerbations. The only PDE-4 inhibitor approved by the Food and Drug Administration, roflumilast is available in 500-μg tablets to be administered once daily. In six placebo-controlled trials involving nearly 4500 patients with COPD of varying severity, the use of roflumilast was associated with reduced COPD exacerbations and improved lung function, as determined by spirometry, with the greatest benefits observed in patients with severe COPD who had chronic bronchitis and a history of frequent exacerbations; clinical efficacy was demonstrated in patients receiving roflumilast alone as well as those receiving concomitant inhaled long-acting β2-agonist (LABA) therapy. The most common adverse events in clinical trials of roflumilast were diarrhea, nausea, and headache. Weight loss and an increased risk of psychiatric events have also been reported in association with roflumilast use. As roflumilast is rapidly converted to its active metabolite via cytochrome P-450 (CYP) isoenzymes, coadministration with strong CYP inducers is not recommended. Research to better define roflumilast's role in COPD management, including a study to determine whether it confers additive benefits when used in combination with standard inhaled therapies other than LABAs, is ongoing.

CONCLUSION

Roflumilast is a safe and effective option for controlling COPD exacerbations in a defined subset of patients for whom the available treatment alternatives are very limited.

Cost-effectiveness of pharmacotherapy for COPD in ambulatory care: a review

RATIONALE, AIMS AND OBJECTIVES

This article conducts a literature review about the cost-effectiveness of pharmacotherapy for chronic obstructive pulmonary disease (COPD) in ambulatory care.

METHODS

Relevant economic evaluations were identified by searching Medline (PubMed) and the National Health Service (NHS) Economic Evaluation Database. The search strategy focused on literature reviews and primary economic evaluations. Economic evaluations were included, which compared pharmacotherapy for COPD, chronic bronchitis or pulmonary emphysema with an alternative in terms of costs and health outcomes.

RESULTS

The majority of economic evaluations show that pharmacotherapy for COPD in ambulatory care is cost-effective. Cost-effectiveness derives from an improvement in lung function and a reduction in the number of exacerbations, which translates into cost savings from fewer hospitalizations. Pharmacotherapy also tends to be more cost-effective in patients with more severe COPD. When applying these results to a specific country or setting, the cost-effectiveness of pharmacotherapy will depend on the distribution of COPD severity among patients, the alternative with which pharmacotherapy is compared, the impact of pharmacotherapy on exacerbations, costs and treatment patterns of exacerbations, and price of pharmacotherapy. Economic evaluations tended to suffer from short-time horizons, restricted scope of included costs and use of various health outcome measures.

CONCLUSIONS

There is a case to be made in favour of economic evaluations from the societal perspective that are based on a decision-analytic model to allow for extrapolation beyond the duration of clinical trials and that use generic health outcome measures such as quality-adjusted life years.

The road not taken: transferability issues in multinational trials

BACKGROUND

National regulatory agencies often have to use cost-effectiveness (CE) data from multinational randomized controlled trials (RCTs) for national decision making on reimbursement of new drugs. We need to make the best use of these patient-level data to obtain estimates of country-specific CE. Several methods, ranging from simple to statistically complex, have existed for years. We investigated which of these methods are used to estimate CE ratios in economic evaluations performed alongside recent, multinational RCTs that enrolled at least 500 patients.

METHODS

In this systematic literature review, studies were classified based on whether resource use, unit costs, health outcomes and utility value sets were obtained from all countries, a subset of countries or one country. We recorded if the study presented trial-wide and country-specific CE results and reported the statistical analyses that were used to estimate them.

RESULTS

We included 21 studies, of which the majority used measurements of health care utilization and health outcomes from all countries to estimate CE. Thirteen studies used a one-country valuation of health care utilization; six used a multi-country valuation. Despite the availability of country-specific utility value sets, none of the studies that presented quality-adjusted life-years (QALYs) used multi-country valuation. Valuation of health care utilization and health outcomes was not always consistent within a study: three studies combined a multi-country valuation of health care utilization, with a one-country valuation of health outcomes. Most studies calculated trial-wide CE estimates, while 11 studies calculated country- or region-specific estimates. Thirteen studies used relatively simple methods, which do not take the possible interaction between the country and treatment effect on health care utilization and health outcomes into account. Eight studies used more advanced statistical methods. Three of them used a fixed-effects modeling approach. Five studies explicitly took the hierarchical structure of the data into account, which leads to more appropriate estimates of population average results and associated standard errors. In this way, they help improve transferability of the published results.

CONCLUSION

Based on this systematic review, we concluded that the uptake of more advanced statistical methods has been relatively slow, while simpler naïve methods are still routinely employed.

Cost effectiveness of adding budesonide/formoterol to tiotropium in COPD in four Nordic countries

OBJECTIVE

Assess the cost effectiveness of budesonide/formoterol (BUD/FORM) Turbuhaler(®)+tiotropium (TIO) HandiHaler(®) vs. placebo (PBO)+TIO in patients with chronic obstructive pulmonary disease (COPD) eligible for inhaled corticosteroids/long-acting β2-agonists (ICS/LABA).

METHODS

The cost-effectiveness analysis was based on the 12-week, randomised, double-blind CLIMB trial. The study included 659 patients with pre-bronchodilator forced expiratory volume in 1 s ≤ 50% and ≥1 exacerbation requiring systemic glucocorticosteroids or antibiotics the preceding year. Patients received BUD/FORM 320/9 μg bid + TIO 18 μg qd or PBO bid + TIO 18 μg qd. Effectiveness was defined as the number of severe exacerbations (hospitalisation/emergency room visit/systemic glucocorticosteroids) avoided. A sub-analysis included antibiotics in the definition of an exacerbation. Resource use from CLIMB was combined with Danish (DKK), Finnish (€), Norwegian (NOK) and Swedish (SEK) unit costs (2010). The incremental cost-effectiveness ratios (ICERs) for BUD/FORM + TIO vs. PBO + TIO were estimated using descriptive statistics and uncertainty around estimates using bootstrapping. Analyses were conducted from the societal and healthcare perspectives in Denmark, Finland, Norway and Sweden.

RESULTS

From a societal perspective, the ICER was estimated at €174/severe exacerbation avoided in Finland while BUD/FORM + TIO was dominant in the other countries. From the healthcare perspective, ICERs were DKK 1580 (€212), €307 and SEK 1573 (€165) per severe exacerbation avoided for Denmark, Finland and Sweden, respectively, while BUD/FORM + TIO was dominant in Norway. Including antibiotics decreased ICERs by 8-15%. Sensitivity analyses showed that results were overall robust.

CONCLUSION

BUD/FORM + TIO represents a clinical and economic benefit to health systems and society for the treatment of COPD in the Nordic countries. (ClinicalTrials.gov Identifier: NCT00496470).

Efficacy and safety of roflumilast in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

BACKGROUND

Roflumilast, a phosphodiesterase 4 inhibitor, has been shown to improve lung function and reduce exacerbation rates, but is associated with adverse events (AEs). The purpose of this study was to systematically review the clinical effectiveness and safety of roflumilast.

METHODS

A systematic search was made of MEDLINE, Cochrane trials database, DARE and CINAHL. Randomized, controlled trials of more than 12 weeks' duration comparing roflumilast with placebo were reviewed. Studies were pooled to yield relative risk (RR), incident rate difference or weighted mean differences with 95% confidence intervals (CIs).

RESULTS

Eight trials (8698 patients) met the inclusion criteria. Roflumilast significantly reduced moderate to severe exacerbations (RR 0.85; 95% CI 0.80-0.91) compared with placebo, but not severe exacerbations (RR 0.83; 95% CI 0.68-1.01) or mortality (RR 0.90; 95% CI 0.63-1.28). Roflumilast significantly improved lung function relative to placebo, but not quality of life measures. AEs (RR 1.11; 95% CI 1.03-1.19) and discontinuations of treatment due to AEs (RR 1.63; 95% CI 1.45-1.84) were significantly more frequent with roflumilast than placebo. In the chronic obstructive pulmonary disease (COPD) Safety Pool (12,054 patients), the overall incidence of serious AEs did not differ between groups. However, atrial fibrillation (0.4% versus 0.2%; p = 0.02) and suicidality (0.08% versus 0%) were more frequent with roflumilast than placebo.

CONCLUSIONS

The efficacy of roflumilast appears modest compared with other available therapies for COPD. Further studies are needed to investigate the risk-benefit ratio and long-term safety of roflumilast before its wider use.

Clinical Considerations for Roflumilast: A New Treatment for COPD

Chronic obstructive pulmonary disease (COPD) causes significant morbidity and mortality and represents the fourth leading cause of death in the world. Roflumilast is the first oral phosphodiesterase inhibitor indicated to reduce the risk of COPD exacerbations in patients with severe COPD associated with chronic bronchitis and history of exacerbations. Roflumilast and its active metabolite have been associated with increased cyclic adenosine monophosphate (cyclic AMP) in the lungs and positive responses with inflammatory markers. Significant improvements in forced expiratory volume (1 sec) have been observed in clinical trials comparing roflumilast with placebo. Combination therapy of roflumilast (500 μg) with long-acting beta agonists resulted in reduced COPD exacerbations in patients with severe COPD. Adverse effects include weight loss, diarrhea, nausea, and psychiatric disturbances. Roflumilast may be associated with significant drug-drug interactions with CYP3A4 inducers (strong) and immunosuppressants. Roflumilast is a promising new agent in the treatment of COPD; however, additional studies comparing roflumilast with inhaled corticosteroids plus long-acting bronchodilators are needed.

Cost effectiveness of pharmacological maintenance treatment for chronic obstructive pulmonary disease: a review of the evidence and methodological issues

BACKGROUND

Over 200 million people have chronic obstructive pulmonary disease (COPD) worldwide. The number of disease-year equivalents and deaths attributable to COPD are high. Guidelines for the pharmacological treatment of the disease recommend an individualized step-up approach in which treatment is intensified when results are unsatisfactory.

OBJECTIVE

Our objective was to present a systematic review of the cost effectiveness of pharmacological maintenance treatment for COPD and to discuss the methodological strengths and weaknesses of the studies.

METHODS

A systematic literature search for economic evaluations of drug therapy in COPD was performed in MEDLINE, EMBASE, the Economic Evaluation Database of the UK NHS (NHS-EED) and the European Network of Health Economic Evaluation Databases (EURONHEED). Full economic evaluations presenting both costs and health outcomes were included.

RESULTS

A total of 40 studies were included in the review. Of these, 16 were linked to a clinical trial, 14 used Markov models, eight were based on observational data and two used a different approach. The few studies on combining short-acting bronchodilators were consistent in finding net cost savings compared with monotherapy. Studies comparing inhaled corticosteroids (ICS) with placebo or no maintenance treatment reported inconsistent results. Studies comparing fluticasone with salmeterol consistently found salmeterol to be more cost effective. The cost-effectiveness studies of tiotropium versus placebo, ipratropium or salmeterol pointed towards a reduction in total COPD-related healthcare costs for tiotropium in many but not all studies. All of these studies reported additional health benefits of tiotropium. The cost-effectiveness studies of the combination of inhaled long-acting β₂-agonists and ICS all report additional health benefits at an increase in total COPD-related costs in most studies. The cost-per-QALY estimates of this combination treatment vary widely and are very sensitive to the assumptions on mortality benefit and time horizon.

CONCLUSIONS

The currently available economic evaluations indicate differences in cost effectiveness between COPD maintenance therapies, but for a more meaningful comparison of results it is important to improve the consistency with respect to study methodology and choice of comparator.

Roflumilast: A Novel Treatment for Chronic Obstructive Pulmonary Disease

Objective:

To evaluate the efficacy and safety of roflumilast, approved by the Food and Drug Administration in February 2011 as a treatment to reduce the risk of chronic obstructive pulmonary disease (COPD) exacerbations in patients with severe COPD associated with chronic bronchitis and a history of exacerbations.

Data Sources:

Literature was retrieved through MEDLINE (1977-December 2011), using the terms roflumilast and COPD. In addition, US government Web sites, including clinicaltrials.gov and fda.gov, were reviewed for pertinent information. Lastly, reference citations from publications identified were reviewed.

Study Selection and Data Extraction:

All articles published in English identified from the data sources were evaluated. For the evaluation of clinical efficacy and safety, only Phase 3 studies were included.

Data Synthesis:

Limited treatment options are available for patients with moderate-to-severe COPD and repeated exacerbations. In 6 published Phase 3 trials to date, roflumilast 500 μg daily exhibited modest improvements in lung function, measured by pre- and postbronchodilator forced expiratory volume in 1 second, and reduced rates of moderate and severe exacerbations. Roflumilast was generally well tolerated, with diarrhea, nausea, and headache the most common adverse events seen in clinical trials, although it has also been associated with an increased risk of neuropsychiatric abnormalities and dose-limiting weight loss. The greatest benefit seen with roflumilast was among patients with moderate-to-severe COPD associated with chronic bronchitis along with a recent history of exacerbations. The benefits were demonstrated with monotherapy and in combination with long-acting β2-agonists or anticholinergic agents.

Conclusions:

Despite its only modest benefits in improving lung function and reducing exacerbation rates, roflumilast serves as a safe and effective option in the treatment of COPD.

Roflumilast, a Novel Phosphodiesterase 4 Inhibitor, for COPD Patients with a History of Exacerbations

Acute exacerbations of COPD (AECOPD) are major clinical events. They are associated with a more rapid decline in lung function, poorer quality of life scores, and an increased risk of dying. Exacerbations that require hospitalization have particular significance. Approximately 40% of the AECOPD patients who require hospitalization will die in the subsequent year. Since many AECOPD require hospitalization, they account for most of the expense of caring for COPD patients. Treatment with long-acting bronchodilators and combination inhaled corticosteroid/long-acting bronchodilator inhalers reduces but does not eliminate AECOPD. Roflumilast, a selective phosphodiesterase 4 (PDE4) inhibitor, is an anti-inflammatory medication that improves lung function in patients with COPD. In patients with more severe airway obstruction, clinical features of chronic bronchitis, and a history of AECOPD, roflumilast reduces the frequency of AECOPD when given in combination with short-acting bronchodilators, long-acting bronchodilators, or inhaled corticosteroids. It is generally well tolerated but the most common adverse effects include diarrhea, nausea, weight loss, and headaches. In clinical trials, patients treated with roflumilast experienced weight loss that averaged just over 2 kg but was primarily due to the loss of fat tissue. Weight loss was least in underweight patients and obese patients experienced the greatest weight loss. An unexpected benefit of treatment with roflumilast was that fasting blood glucose and hemoglobin A1c levels improved in patients with comorbid type 2 diabetes mellitus. Roflumilast, the first selective PDE4 inhibitor to be marketed, is a promising drug for the management of COPD patients with more severe disease.

Effectiveness of ribavirin and corticosteroids for severe acute respiratory syndrome

OBJECTIVE

Ribavirin and corticosteroids were used widely as front-line treatments for severe acute respiratory syndrome; however, previous evaluations were inconclusive. We assessed the effectiveness of ribavirin and corticosteroids as the initial treatment for severe acute respiratory syndrome using propensity score analysis.

METHODS

We analyzed data on 1755 patients in Hong Kong and 191 patients in Toronto with severe acute respiratory syndrome using a generalized propensity score approach.

RESULTS

The adjusted excess case fatality ratios of patients with severe acute respiratory syndrome receiving the combined therapy of ribavirin and corticosteroids within 2 days of admission, compared with those receiving neither treatment within 2 days of admission, were 3.8% (95% confidence interval, -1.5 to 9.2) in Hong Kong and 2.1% (95% confidence interval, -44.3 to 48.5) in Toronto.

CONCLUSIONS

Our results add strength to the hypothesis that the combination of ribavirin and corticosteroids has no therapeutic benefit when given early during severe acute respiratory syndrome infection. Further studies may investigate the effects of these treatments later in disease course.

Roflumilast: an oral, once-daily selective PDE-4 inhibitor for the management of COPD and asthma

BACKGROUND

Roflumilast is a selective phosphodiesterase-4 inhibitor with a broad range of anti-inflammatory actions. Studies in asthma and chronic obstructive pulmonary disease (COPD) have demonstrated that it can improve lung function and reduce inflammation.

OBJECTIVE

To review the clinical data on roflumilast in COPD and asthma.

METHODS

A PubMed search using the term roflumilast was used to identify articles, and the bibliographies of the identified articles were reviewed to identify other relevant reports. All roflumilast abstracts from the 2006 and 2007 International Meetings of the American College of Chest Physicians, American Thoracic Society and European Respiratory Society were also reviewed.

RESULTS/CONCLUSION

The preliminary studies of roflumilast in COPD and asthma have only shown modest clinical benefits and may be associated with gastrointestinal side effects. Further studies are required to clarify the role of roflumilast in the management of COPD and asthma.