Cost-effectiveness of Tofacitinib in the Treatment of Moderate to Severe Rheumatoid Arthritis in South Korea

PURPOSE

This study evaluated the cost-effectiveness of introducing tofacitinib, an oral Janus kinase inhibitor, to the treatment of Korean patients with rheumatoid arthritis (RA) and an inadequate response to conventional disease-modifying antirheumatic drugs.

METHODS

In this cost-utility analysis model, patients transitioned through treatment sequences based on Korean guidelines for RA patients with inadequate response to conventional disease-modifying antirheumatic drugs. Lifetime health-related quality of life and costs were evaluated. Characteristics of the model cohort were based on those reported by the Oral Rheumatoid Arthritis phase 3 triaL (ORAL) Standard randomized Controlled trial of tofacitinib or adalimumab versus placebo. Efficacy was assessed using American College of Rheumatology response rates, converted to the changes in Health Assessment Questionnaire-Disability Index (HAQ-DI) scores, based on tofacitinib clinical trials data. Published clinical trial data on discontinuation rates of the indicated drugs were incorporated in the model. The HAQ-DI scores were mapped onto utility values to calculate outcomes in terms of quality-adjusted life-years (QALYs); HAQ-DI-to-utility (EuroQoL 5D) mapping was based on data from 5 tofacitinib clinical trials. Costs were analyzed from a societal perspective, with values expressed in 2013 Korean won (KRW). Cost-effectiveness is presented in terms of incremental cost-effectiveness ratios (ICERs). One-way sensitivity analyses were performed to assess the robustness of the model.

FINDINGS

First-line tofacitinib used before the standard of care (base-case analysis) increased both treatment costs and QALYs gained versus the standard-of-care treatment sequence, resulting in an ICER of KRW 13,228,910 per QALY. Tofacitinib also increased costs and QALYs gained when incorporated as a second-, third-, or fourth-line therapy. The inclusion of first-line tofacitinib increased the duration of active immunomodulatory therapy from 9.4 to 13.2 years. Tofacitinib-associated increases in costs were attributable to the increased lifetime drug costs. In sensitivity analyses, variations in input parameters and assumptions yielded ICERs in the range of KRW 6,995,719 per QALY to KRW 37,450,109 per QALY.

IMPLICATIONS

From a societal perspective, the inclusion of tofacitinib as a treatment strategy for moderate to severe RA is cost-effective; this conclusion was considered robust based on multiple sensitivity analyses. The study was limited by the lack of clinical data on follow-up therapy after tofacitinib administration and a lack of long-term data on discontinuation of drug use.

Cost-effectiveness analysis of low density lipoprotein cholesterol-lowering therapy in hypertensive patients with type 2 diabetes in Korea: single-pill regimen (amlodipine/atorvastatin) versus double-pill regimen (amlodipine+atorvastatin)

OBJECTIVES

Single-pill combination therapy (amlodipine/atorvastatin) might be more effective than double-pill therapy (amlodipine+atorvastatin) in patients with diabetes and concomitant hypertension requiring statin therapy. We compared the cost-effectiveness of a single-pill with that of double-pill for control of low density lipoprotein cholesterol (LDL-C) levels, with the ultimate goal of cardiovascular disease prevention, in these patients using a cost-effectiveness analysis model that considered medication adherence.

METHODS

Effectiveness was defined as the percentage (%) attainment of target LDL-C levels (<100 mg/dL) based on adherence for each therapy. Adherence was defined as compliance to medication (≥80% proportion of days covered). A systematic review of the literature was conducted to determine the proportion of patients who were adherent and target goal attainment based on adherence level. The annual medication costs were based on the adherence levels for each regimen. The average cost-effectiveness ratio (ACER) was calculated as the cost per % attainment of the target LDL-C level.

RESULTS

The ACER for the single-pill regimen was lower than for the double-pill regimen (4,123 vs. 6,062 Korean won per 1% achievement of target goal). Compared with the double-pill, the medication costs were approximately 32% lower with the single-pill.

CONCLUSION

A single-pill for reductions in LDL-C is cost-effective compared with double-pill in hypertensive patients with type 2 diabetes.

Amlodipine and cardiovascular outcomes in hypertensive patients: meta-analysis comparing amlodipine-based versus other antihypertensive therapy

BACKGROUND/AIMS

This meta-analysis compared the effects of amlodipine besylate, a charged dihydropyridine-type calcium channel blocker (CCB), with other non-CCB antihypertensive therapies regarding the cardiovascular outcome.

METHODS

Data from seven long-term outcome trials comparing the cardiovascular outcomes of an amlodipine-based regimen with other active regimens were pooled and analyzed.

RESULTS

The risk of myocardial infarction was significantly decreased with an amlodipine-based regimen compared with a non-CCB-based regimen (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.84 to 0.99; p = 0.03). The risk of stroke was also significantly decreased (OR, 0.84; 95% CI, 0.79 to 0.90; p < 0.00001). The risk of heart failure increased slightly with marginal significance for an amlodipine-based regimen compared with a non-CCB-based regimen (OR, 1.14; 95% CI, 0.98 to 1.31; p = 0.08). However, when compared overall with β-blockers and diuretics, amlodipine showed a comparable risk. Amlodipine-based regimens demonstrated a 10% risk reduction in overall cardiovascular events (OR, 0.90; 95% CI, 0.82 to 0.99; p = 0.02) and total mortality (OR, 0.95; 95% CI, 0.91 to 0.99; p = 0.01).

CONCLUSIONS

Amlodipine reduced the risk of total cardiovascular events as well as all-cause mortality compared with non-CCB-based regimens, indicating its benefit for high-risk cardiac patients.

Pre-emptive and multi-modal perioperative pain management may improve quality of life in patients undergoing spinal surgery

BACKGROUND

Compared to an abundance of data on surgical techniques for degenerative spine conditions and the outcomes thereof, little is available to guide optimal perioperative pain management after spinal surgery. The aim of this study was to survey patterns of perioperative pain management after spinal surgery and to investigate the effects of perioperative pain management, such as pre-emptive analgesia and multi-modal postoperative pain management, on acute postoperative satisfaction, pain reduction, and health-related quality of life in patients undergoing spinal surgery.

STUDY DESIGN

Non-blind multicenter prospective observational clinical series.

SETTING

Seventeen tertiary hospitals (14 hospitals attached to medical colleges and 3 general hospitals).

METHODS

Pain management protocols of 393 patients (153 men, 240 women; mean age of 67 years, ranging from 21 to 91 years) from 17 tertiary hospitals after spinal surgery for degenerative spine disease were evaluated using a self-administered questionnaire.

RESULTS

A total of 79 (20%) patients received pre-emptive analgesics, which included cyclooxygenase-2 (COX-2) inhibitors, with or without administration of anticonvulsants, immediately before surgery at the time of antibiotic prophylaxis. Postoperative pain was managed mainly by multi-modal therapy (363 cases, 92%), along with various combinations of patient controlled anesthesia (PCA), conventional nonsteroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors, and narcotics. Self-reported levels of pain were not significantly different among postoperative multiple modalities of pain management, but were different significantly for pre-emptive pain management regimens (P < 0.05, independent t-test). The number of patients that reported the self-administrative use of PCA was higher in the no pre-emptive pain management group compared to the pre-emptive group (P < 0.05). In regards to EQ-5D usual activity, depression/anxiety and self-care improved significantly in the pre-emptive pain management group when measured at 2 weeks postoperative (P < 0.05).

LIMITATIONS

The limitation of our study is that it is not a randomized controlled observational study.

CONCLUSIONS

Pre-emptive analgesia and multi-modal pain management after spinal surgery may lead to better health-related quality of life, greater patient satisfaction, and less postoperative pain.

Evaluation of the willingness-to-pay for cancer treatment in Korean metastatic breast cancer patients: a multicenter, cross-sectional study

AIMS

To evaluate the inherent value of breast cancer therapy a willingness-to-pay (WTP) study was conducted in Korean patients with metastatic breast cancer.

METHODS

Patients were prospectively enrolled from four study centers and completed quality of life questionnaires to reflect their status pre-cancer and their current health status. Clinical and socioeconomic data were collected to characterize the population and utilize during modeling. Patients' WTP for breast cancer treatment was assessed using an open-ended question following three rounds of bidding to better hone in on their maximal WTP, starting with one of three randomly assigned start bids. Predictors of patient WTP was evaluated using linear regression models. Associations between WTP and other parameters were evaluated with correlations.

RESULTS

Korean metastatic breast cancer patients were WTP an average of KRW 8 696 329 (US$7555) per month to return to their pre-cancer health state, with those who were recently diagnosed as WTP the most (KRW 12 955 000 [$11 254]). WTP was closely associated with the patient's education level, income, personal financial difficulties, Eastern Cooperative Oncology Group performance status, and their experience of arm symptoms.

CONCLUSION

The results suggest that patients are WTP significant amounts per month for treatment. Breast cancer patients are heavily burdened physically, mentally and financially, and the present study indicated this significant financial burden by disclosing its relationship with WTP. Providing a better understanding of the inherent value of treatment will allow Koreans to better evaluate treatment in the coming era of personalized medicine.

Gastrodia Elata Bl Attenuates Cocaine-Induced Conditioned Place Preference and Convulsion, but not Behavioral Sensitization in Mice: Importance of GABA(A) Receptors

It has been suggested that GABAergic neurotransmission can modulate cocaine dependence and seizure activity. Since Gastrodia elata Bl (GE), an oriental herb agent, has been shown to enhance GABAergic transmission, we examined whether GE affects cocaine-induced seizures, conditioned place preference (CPP), and behavioral sensitization in mice. Treatment with GE (500 or 1000 mg/kg, p.o.) significantly delayed seizure onset time and significantly shortened seizure duration induced by cocaine (90 mg/kg, i.p.). In addition, cocaine (15 mg/kg, i.p.)-induced CPP was significantly attenuated by GE in a dose-dependent manner. However, GE did not significantly alter behavioral sensitization induced by cocaine (15 mg/kg, i.p.). In order to understand whether GABAergic receptors are implicated in GE-mediated pharmacological action in response to cocaine, GABA_A receptor antagonist bicuculline and GABA_B receptor antagonist SCH 50911 were employed in the present study. GE-mediated attenuations on the cocaine-induced seizures and CPP were significantly reversed by bicuculline (0.25 or 0.5 mg/kg, i.p.), but not by SCH 50911 (1.5 or 3.0 mg/kg, i.p.). Therefore, our results suggest that GE attenuates cocaine-induced seizures and CPP via, at least in part, GABA_A receptor activation.

Gastrodia elata bl attenuates methamphetamine-induced dopaminergic toxicity via inhibiting oxidative burdens

It has been recognized that Gastrodia elata Bl (GE), an oriental herb medicine, ameliorates various neurological disorders, that GE modulates the monoaminergic and GABAergic systems, and that GE possess antioxidant activities. We examined whether GE affects methamphetamine (MA)-induced striatal dopaminergic toxicity in mice. Treatment with MA (7.5 mg/kg, i.p. × 4) resulted in significant decreases in behavioural activity (as shown by locomotor activity and rota rod performance), dopamine level, tyrosine hydroxylase (TH) activity, and TH protein expression (as evaluated by immunocytochemistry and western blot analysis). In addition, MA treatment showed significant increases in lipid peroxidation [as evaluated by 4-hydroxy-2-nonenal (4-HNE) expression and malondialdehyde formation], protein oxidation (as shown by protein carbonyl expression and its formation), and reactive oxygen species (ROS) formation. Treatment with GE significantly attenuates MA-induced behavioural and dopaminergic impairments, and oxidative stresses in a dose-dependent manner. Our results suggest that GE treatment shows anti-dopaminergic effects in response to MA insult via, at least in part, inhibiting oxidative stresses in the striatum of the mice.

Mapping the cancer-specific EORTC QLQ-C30 and EORTC QLQ-BR23 to the generic EQ-5D in metastatic breast cancer patients

PURPOSE

To develop a mapping algorithm for a conversion of the EORTC QLQ-C30 and EORTC QLQ BR-23 into the EQ-5D-derived utilities in metastatic breast cancer (MBC) patients.

METHODS

We enrolled 199 patients with MBC from four leading Korean hospitals in 2009. EQ-5D utility, cancer-specific (QLQ-C30) and breast cancer-specific quality of life data (QLQ-BR23) and selected clinical and demographic information were collected from the study participants. Ordinary least squares regression models were used to model the EQ-5D using QLQ-C30 and QLQ-BR23 scale scores. To select the best model specification, six different sets of explanatory variables were compared.

RESULT

Regression analysis with the multiitem scale scores of QLQ-C30 was the best-performing model, explaining for 48.7% of the observed EQ-5D variation. Its mean absolute error between the observed and predicted EQ-5D utilities (0.092) and relative prediction error (2.784%) was among the smallest. Also, this mapping model showed the least systematic errors according to disease severity.

CONCLUSIONS

The mapping algorithms developed have good predictive validity, and therefore, they enable researchers to translate cancer-specific health-related quality of life measures to the preference-adjusted health status of MBC patients.

The financial burden of asthma: a nationwide comprehensive survey conducted in the republic of Korea

Purpose

Asthma-related morbidity and mortality are increasing, and the financial burden imposed by this condition will substantially increase. Nevertheless, little information is available regarding the nature and magnitude of the burden due to asthma at the national level. This study was conducted to characterize the financial burden imposed by asthma in the Republic of Korea at the national level.

Methods

The overall prevalence of asthma and the costs of related medical services were determined using data from the National Health Insurance Corporation, which is responsible for the National Health Insurance scheme. Indirect costs, including expenditures on complementary and alternative medicines, and the economic impact of an impaired quality of life (intangible costs) were estimated by surveying 660 asthmatics, and these estimates were transformed to the national level using the prevalence of asthma.

Results

The prevalence of asthma and total costs related to the disease in 2004 were 4.19% and $2.04 billion, respectively. Direct costs and indirect costs contributed equally to total costs (46.9% and 53.1%, respectively). However, when intangible costs were included, total costs rose to $4.11 billion, which was equivalent to 0.44% of the national gross domestic product in 2004.

Conclusions

The results provide evidence that asthma is a major health cost factor in the Republic of Korea and that intangible costs associated with asthma are significant cost drivers.

A catalogue of EQ-5D utility weights for chronic diseases among noninstitutionalized community residents in Korea

OBJECTIVE

The main purpose of this study is to provide a national catalog of preference-based utility weights associated with major chronic diseases in Korea.

METHODS

The 2005 Korea National Health and Nutrition Examination Survey was used to get EQ-5D scores for 27 major chronic diseases. The independent detrimental effect of each chronic disease was estimated using a censored least absolute deviations regression.

RESULTS

The respondents (60.5%) rated their health as perfect or 11111 on the EQ-5D scale showing ceiling effect. Stroke (0.5067 approximately 0.5756) was the condition of the lowest EQ-5D utility weight and was followed by renal failure (0.6637 approximately 0.7739), angina pectoris (0.7325 approximately 0.8364), and arthritis (0.7621 approximately 0.8644). The marginal impact of each chronic disease after adjusting for age, sex, education, income, marital status, and the number of comorbid conditions was largest in stroke, arthritis, cancer, renal failure, and herniated disc.

CONCLUSION

This study provided a nationally representative catalog of utility weights for major chronic diseases in Korea. The three most burdensome chronic diseases among Korean adults based on the regression analysis were stroke, arthritis, and cancer.

Are league tables controlling epidemic of caesarean sections in South Korea?

OBJECTIVE

To assess the impact of the publication of hospital caesarean section rates on the reduction of these rates in South Korea, and explore associated factors contributing to the decrease.

DESIGN

Observational study.

SETTING

South Korea.

SAMPLE

Two hundred and sixty-three hospitals in South Korea.

METHODS

The caesarean section rates of 263 hospitals, before and after the release of caesarean section rates to the public, were obtained. The factors influencing the reduction in hospital caesarean section rates were also explored using multiple logistic regression.

MAIN OUTCOME MEASURE

Hospital caesarean section rates.

RESULTS

After the release of information in 2000, the total (clinic and hospital) caesarean section rates in 2000 and 2001 decreased to 38.6% and 39.6%, respectively, from 43.0% in 1999. Caesarean section rates for hospitals were 45.9%, 42.7% and 44.6% in 1999, 2000 and 2001, respectively. Hospitals with the highest baseline caesarean section rates (OR 9.4, 95% CI 4.2-21.0) and highest number of deliveries (OR 8.1, 95% CI 2.1-31.1) were significant factors contributing independently to a decrease in caesarean section rates. Market share, competition, characteristics of revenue generation and ownership did not significantly influence the change of rates.

CONCLUSION

The public release of information on caesarean section rates in Korea has reversed the ever-increasing trend in these rates. Hospitals with pre-existing high caesarean section rates or a larger number of deliveries were influenced by the information release and could be the main targets for interventions to decrease these rates.

A new stilbene diglycoside from Rheum undulatum

A new stilbene diglycoside, piceatannol-3, 4'-O-beta-D-diglucopyranoside (I), together with desoxyrhaponticin (II), emodin-1-O-beta-D-glucopyranoside (III), and physcion-8-O-b-D-glucopyranoside (IV), were isolated from the rhizomes of cultivated Korean rhubarb rhizomes (Rheum undulatum), Jong DaeWhang, and the structures of I-IV were identified on the basis of chemical and spectral evidences.

Lupane-glycoside of Acanthopanax trifoliatus forma tristigmatis leaves

This report contains the first characterization of acanthodiolglycoside which belongs to pentacyclic lupane triterpene glycoside.

Anti-platelet aggregation activity of stilbene derivatives from Rheum undulatum

In continued studies on cultivated Korean rhubarb rhizomes (Rheum undulatum), three known stilbenes (desoxyrhapontigenin, rhapontigenin, piceatannol) have been screened for activity on blood platelet aggregation. Both rhapontigenin and desoxyrhapontigenin exhibited strong inhibition on the aggregation induced by arachidonic acid and collagen. However, piceatannol did not show inhibition. These inhibitory effects may partially contribute to anti-blood stagnancy activity of rhubarb.

Testicular cycles in three species of Korean frogs: Rana nigromaculata, Rana rugosa, and Rana dybowskii

Seasonal changes in testicular structure and function in three species of Korean frogs (Rana nigromaculata, R. rugosa, and R. dybowskii) having different breeding seasons and habitats were examined throughout the year. R. nigromaculata live in rice fields and breed in early May. Their gonadosomatic index (GSI) and testis weight decreased slightly from May until July, but increased markedly from August to high levels through December. The diameter (cross-sectional area) of seminiferous tubules changed little from January until August, increased sharply from September through October, and decreased thereafter. In seminiferous tubules, the number of primary spermatogonia (I SPG) was low from January-March, increased from April to maximum levels by May-June, and decreased subsequently. The number of spermatids (SPT) was highest from November to March, decreased to nondetectable levels in May, and increased markedly from September to November. Spermiation was most active during March and April. R. rugosa, which live in streams and breed during May-June, exhibited no changes in GSI, testis weight, or seminiferous tubule size throughout the year. The number of I SPG was high during May-August and that of secondary spermatogonia (II SPG) was highest in August. The number of SPT increased to high levels in November-December. Active spermiation occurred from January to April in this frog. In R. dybowskii, which live in the mountains and breed from late February to early March, the number of I SPG gradually increased from April through August; however, essentially no other spermatogenic cells were observed from January to July. A marked increase in early spermatogenic cells appeared during August-September and was followed by an increase in SPT from November to December. From December to March the number of spermatozoa increased and spermiation occurred. In general, testicular testosterone levels were high in the winter and low in summer in all three species, and positively correlated with the number of interstitial cells and the size of their nucleus.

Steroidogenic shift by cultured ovarian follicles of Rana dybowskii at breeding season

The steroid secretory activity of cultured ovarian follicles of Rana dybowskii and the activities of relevant steroidogenic enzymes were examined during the natural hibernation period (October-February). Enzyme activities were measured indirectly by monitoring the conversion of exogenous substrates to products by isolated follicles. Follicles were incubated for 6 h in amphibian Ringer in the presence or absence of frog pituitary homogenate (FPH, 0.1 pituitary/2 ml) and/or various steroid precursors. Progesterone (P4), 17 alpha-hydroxyprogesterone (17 alpha-OHP) or testosterone (T) secreted by the follicles into the medium were measured by RIA. In the presence of FPH, high levels of P4 were produced by follicles at the early and mid-hibernation period (695 and 898 pg/follicle, respectively) whereas markedly elevated levels of P4 were produced during late hibernation (1,393 pg/follicle) (just prior to or breeding season, February). In contrast, high levels of T were produced by the follicles early in hibernation (1,206 pg/follicle) while negligible levels were produced in late hibernation (69 pg/follicle). Higher levels of 17 alpha-OHP were produced by follicles at early and mid hibernation (594 and 705 pg/follicle, respectively) than in later hibernation (221 pg/follicle). Addition of exogenous pregnenolone markedly increased P4 levels in a dose-dependent manner when added to follicles at early and late stages of hibernation: FPH addition further enhanced conversion of pregnenolone. Similarly, addition of androstenedione (AD) increased T levels in a dose-dependent manner by these follicles. However, following addition of exogenous P4, less 17 alpha-OHP was produced by follicles collected in late hibernation as compared to those collected earlier.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes of cardiac output during treadmill exercise by impedance cardiography

Nine athletes and ten nonathletes were selected randomly to study the changes of cardiac function during exercise by impedance cardiography. The speed of the treadmill was maintained at 3.4 mph, and its grade was increased by 1% (Balke protocol). The exercise was continued until the target heart rate (THR), 85% of maximum oxygen uptake (VO2max). The measured parameters for pre- and post-exercise were stroke volume (SV), heart rate (HR), and cardiac output (CO). Average stroke volume of athletes at pre-exercise, 71.1 ml, was higher than that of nonathletes, 64.6 ml, and stroke volume of the former at post-exercise, 97.0 ml, was also higher than that of the latter, 85.2 ml. Therefore, despite the lower heart rate, cardiac outputs of athletes at pre- and post-exercise, 4.98 and 16.3 L/min, were higher than those of nonathletes, 4.87 and 14.2 L/min. For the second phase of the study, cardiac outputs of three subjects were measured during the continuous treadmill exercise with newly developed electrodes and shoes for minimizing motion artifact. Though there were several studies measuring cardiac output during continuous bicycle exercise, this is thought to be the first study in the world measuring cardiac output during continuous treadmill exercise without aid of ensemble averaging.

Epidemiologic study of 600 villagers of oral precancerous lesions in Bilugyun: preliminary report

A house-to-house survey of 11 villages selected by random sampling was carried out in Bilugyun. Chaung-zone township. Mon State of South Eastern Burma to study the prevalence of oral precancerous lesions and smoking and chewing. A total of 6000 villagers who were above 15 years at the time of this study were examined. The prevalence of preleukoplakia was 0.3%, leukoplakia 1.7%, lichen planus 0.4%, leukokeratosis nicotina palati 2.3, erythroplakia 0.1%, submucous fibrosis 0.1%, and cancer 0.03%. A correlation was done between habits and lesions.