Cost-Effectiveness of Recombinant Factor IX Fc Prophylaxis and Recombinant Factor IX On-Demand Treatment in Patients with Haemophilia B Without Inhibitors

INTRODUCTION

Recombinant factor IX (rFIX) and recombinant FIX Fc fusion protein (rFIXFc) are standard half-life and extended half-life FIX replacement therapies, respectively, and represent established treatment options indicated for adults and children with haemophilia B. These FIX replacement therapies can be administered as prophylaxis (to prevent bleeding) or 'on-demand' (to stop bleeding). This analysis aimed to estimate the cost-effectiveness of once-weekly prophylaxis with rFIXFc versus on-demand treatment with rFIX in patients with haemophilia B without inhibitors in the Italian healthcare setting.

METHODS

A Markov model was developed to assess a hypothetical cohort of adolescent or adult male patients (≥ 12 years) with haemophilia B (FIX level of ≤ 2 IU/dL) without inhibitors. Model inputs were derived from the pivotal phase 3 clinical studies for rFIXFc and rFIX, published literature and assumptions when published data were unavailable. The model employed a lifelong time horizon with 6-monthly transitions between health states, and it estimated total costs, total quality-adjusted life years (QALYs), number of bleeds, number of surgeries and incremental cost-effectiveness ratio.

RESULTS

rFIXFc prophylaxis was associated with lower total costs per patient (€5,308,625 versus €6,564,510) and greater total QALYs per patient (15.936 versus 11.943) compared with rFIX on-demand; rFIXFc prophylaxis was therefore the dominant treatment strategy. The model also demonstrated that rFIXFc prophylaxis was associated with fewer incremental bleeds (- 682.29) and surgeries (- 0.39) compared with rFIX on-demand.

CONCLUSIONS

rFIXFc prophylaxis provides improved health outcomes and lower costs, and represents a cost-effective treatment option compared with rFIX on-demand for adolescent and adult male patients with haemophilia B. This comparative assessment of cost-effectiveness should help to inform both clinicians and healthcare policy makers when making treatment decisions for patients with haemophilia B.

Cost-Utility Analysis Comparing Pegcetacoplan to Anti-C5 Monoclonal Antibodies in the Treatment of Paroxysmal Nocturnal Hemoglobinuria

Background

Paroxysmal nocturnal hemoglobinuria is a rare, acquired disease characterized by hemolytic episodes and associated with significant clinical burden. The introduction of C5 inhibitory monoclonal antibodies (C5i) represented a major breakthrough in PNH treatment, effectively reducing intravascular hemolysis (IVH) but showing limited impact on extravascular hemolysis (EVH). In 2021, the C3 inhibitor pegcetacoplan was approved by EMA and recently reimbursed in Italy, which also has the advantages in the reduction of both IVH and EVH, increasing hemoglobin values and simultaneously improving the quality of life and fatigue of patients. A cost-utility analysis was developed to compare pegcetacoplan to C5i (eculizumab and ravulizumab) in the PNH population who remain anemic after treatment with C5i for at least 3 months.

Materials and Methods

The analysis employed a Markov model with a 5-year time horizon whereby patients can transition among 3 PNH health states, adopting the perspective of the Italian NHS. Efficacy data were sourced from the PEGASUS study, with drug prices reflecting ex-factory costs. Additionally, costs associated with resource utilization, adverse events, and complications were estimated based on outpatient and hospital care rates, excluding indirect expenses. Utility and disutility values related to transfusions were also considered, with pegcetacoplan allowing for dose escalation.

Results

The cumulative cost of treatment per individual patient at 5 years was estimated to be €1,483,454 for pegcetacoplan, €1,585,763 for eculizumab, and €1,574,826 for ravulizumab. Pegcetacoplan demonstrated a superior increase in quality-adjusted life years (QALYs) compared to both eculizumab (0.51 increase) and ravulizumab (0.27 increase). Furthermore, pegcetacoplan showed a reduction in complication management costs (€22,891 less compared to eculizumab and €22,611 less compared to ravulizumab) and lower transfusion-related expenses (€14,147 less than both C5i treatments).

Conclusion

Pegcetacoplan emerged as the dominant strategy in this analysis, being more effective, less expensive and improves quality of life in the analyzed population affected by PNH.

Budget impact analysis for avatrombopag in the treatment of chronic primary immune thrombocytopenia in adult patients refractory to other treatments

Introduction: Primary immune thrombocytopenia is a rare autoimmune disease characterised by a decreased platelet count resulting in an increased risk of bleeding events and even life-threatening haemorrhages. Thrombopoietin receptor agonists (TPO-RAs) are the standard of care second-line therapy for adult patients with chronic immune thrombocytopenia. The first TPO-RAs approved and reimbursed in Italy, eltrombopag and romiplostim, while effective, pose some issues in terms of safety (e.g., hepatotoxicity) or general management (e.g., dietary restrictions). Avatrombopag, an effective and well-tolerated TPO-RA, was recently granted reimbursement. Methods: A 3-year (2023-2025) budget impact analysis (BIA) was conducted to estimate its impact on the Italian National Health Service (NHS). Two scenarios were compared, of which one represents the current situation, without avatrombopag, and the other provides for an increasing market share of avatrombopag (up to 26.6%). Results: BIA shows that the increase in the use of avatrombopag correlates with savings for NHS: in the first year, saving would be €1,300,564, increasing to €2,774,210 in the third year, for a total of €6,083,231 over the 3-year period. The sensitivity analysis confirmed these savings in the scenario with avatrombopag. Conclusions: Based on this BIA, the introduction and reimbursement of avatrombopag is an efficient and advantageous choice for the Italian NHS.

Direct, precise, enzyme-free detection of miR-103–3p in real samples by microgels with highly specific molecular beacons

Low abundance, small size, and sequence similarities render microRNA (miRNAs) detection challenging, particularly in real samples, where quantifying weakly expressed miRNAs can be arduous due to interference of more abundant molecules. The standard quantitative reverse transcription polymerase chain reaction (qRT-PCR) requires multiple steps, thermal cycles, and costly enzymatic reactions that can negatively affect results. Here we present a direct, precise, enzyme-free assay based on microgels particles conjugating molecular beacons (MB) capable of optically detecting low abundant miRNAs in real samples. We validate the applicability of microgels assay using qRT-PCR as a reference technology. As a relevant case, we chose miR-103-3p, a valuable diagnostic biomarker for breast cancer, both in serum samples and MCF7 cells. As a result, microgels assay quantifies miRNA molecules at room temperature in a single step, 1 h (vs. 4 hrs for qRT-PCR) without complementary DNA synthesis, amplification, or expensive reagents. Microgels assay exhibits femtomolar sensitivity, single nucleotide specificity, and a wide linear range (10²-10⁷ fM) (wider than qRT-PCR), with low sample consumption (2 μL) and excellent linearity (R²= 0.98). To test the selectivity of the microgel assay in real samples, MCF7 cells were considered where the pool of 8 other miRNAs were further upregulated with respect to miRNA 103-3p. In such complex environments, microgels assay selectively detects the miRNA target, mainly due to MB advanced stability and specificity as well as high microgel antifouling properties. These results show the reliability of microgels assay to detect miRNAs in real samples.

Early Palliative Home Care versus Hospital Care for Patients with Hematologic Malignancies: A Cost-Effectiveness Study

Background: There is paucity of data on the potential value of early palliative home care for patients with hematologic malignancies. Objective: To compare costs, use of resources, and clinical outcomes between an early palliative home care program and standard hospital care for active-advanced or terminal phase patients. Patients and Methods: In this real-life, nonrandomized comparative study, the allocation of advanced/terminal phase patients to either home or hospital was based on pragmatic considerations. Analysis focused on resources use, events requiring blood unit transfusions or parenteral therapy, patient-reported symptom burden, mean weekly cost of care (MWC), cost-minimization difference, and incremental cost-effectiveness ratio (ICER). Results: Of 119 patients, 59 patients cared at home were more debilitated and had a shorter survival than the 60 in hospital group (p = 0.001). Nevertheless, symptom burden was similar in both groups. At home the mean weekly number of transfusions (1.45) was lower than that at hospital (2.77). Higher rate of infections occurred at hospital (54%) versus home (21%; <0.001). MWC for hospitalization was significantly higher in a 3:1 ratio versus home care. Compared with hospital, domiciliary assistance produced a weekly saving of € 2314.9 for the health provider, with a charge of € 85.9 for the family, and was cost-effective by an ICER of € -7013.9 of prevented days of care for avoided infections. Conclusions: Current findings suggest that costs of early palliative home care for patients with hematologic malignancies are lower than standard hospital care costs. Domiciliary assistance may also be cost-effective by reducing the number of days to treat infections.

[Intragastric balloon in bariatric surgery]

Intragastric balloon (BIB) is a mechanical restrictive device formed by a silicone wrapper inserted endoscopically in the stomach, filled with 500 cc of physiological blue methyl solution and kept in situ for 6 months. In two years 98 intragastric balloon have been set in 88 patients at the average age of 37.1 years, of 41.9 of BMI and 47.6 kg of weight. Complications were intolerance, gastro-oesophageal reflux, break and/or deflation and meteorism. BIB is an effective procedure in the temporary treatment of obesity leading to satisfactory weight loss and to short-term improvement of comorbidities.

[Operative table-induced pressure ulcers]

The Authors conducted a study on 780 patients who underwent surgery. Fourteen patients developed operative table-induced pressure ulcers of different gravity. This paper is a description of these 14 cases. From the literature and from experience we know that the major exogenous risk factor for intraoperative pressure ulcers is the operation time. Therefore, special attention should be paid to preoperative, intraoperative and postoperative prevention. The knowledge of the pathology, specialized personnel and the use of appropriate facilities can reduce the risks of complication that are important sanitary and economic issue.

[Intraoperative limphonodal mapping in gastric, pulmonary and large bowel tumors. The sentinel limphonode technique]

The concept of the sentinel lymphatic node was introduced by Cabanas in 1977, but it has proved to be successful for the treatment of the melanoma and breast cancer only since the 90s. Many studies have recently extended this technique to other neoplasias. This study deals with 36 patients who were to undergo surgery for 14 gastric adenocarcinomas, 11 of the colon and 11 pulmonary. Once the neoplastic mass was detected, 2 to 5 ml of a vital dye (Blu Patent) were injected in the serosa along the perimeter of the tumor by means of several 0.5 ml injections. A lymphatic node was diagnosed in 22 patients, respectively 10 gastric neoplasias, 6 pulmonary, 6 of the colon. In 14 cases the lymphatic node was found to be negative, in 8 cases positive. In the remaining 14 patients the lymphatic node was not detected. Although data do not always agree, the sentinel lymphatic node technique seems to have been successful for this kind of tumors. For this reason we have carried out this study and published our first data.

[Neurinoma of the brachial plexus: 2 case reports]

Neurinomas, also referred to as neurilemmomas and schwannomas, are rare benign tumours of the peripheral nerves. A small percentage of these lesions arise from the brachial plexus. The Authors report two cases of schwannoma arising from the brachial plexus. Such lesions, usually asymptomatic, may cause sensitivity alterations or, less frequently, motor deficits in the involved arm. Tumour enucleation, avoiding damage to any of the nervous fascicles, is the treatment of choice.

[Use of abdominal wall retractor Laparo Tenser in gasless laparoscopic cholecystectomy]

High pressure CO2-peritoneum for laparoscopic surgery is not indicated in patients with impairment of cardiorespiratory and renal function and in high risk patients and in obesity. On the other site the uncontrolled abdominal insufflation and the blind insertion of the first trocar in patients with extended intraperitoneal adhesions, often cause bleeding and the intestinal loops dislocation, and can determine visceral lesions. In these patients gasless technique with an abdominal laparolifter can be employed. We report an experience of 36 patients undergoing laparoscopic cholecystectomy by a subcutaneous planar retractor. It was observed a good operative exposure in 83.3%; the surgery was safely performed in 88.8%. Two suprafascial hematoma related to the insertion of the needles of the Laparo Tenser occurred. A regular post-operative discharge was observed in 84.4%. These good results supports the extension of the laparoscopic approach for the cholecystectomy to complicated or to high risk patients.

[Essential varicocele. Which treatment?]

Purpose of the paper is to sum up the problem of surgery of idiopathic varicocele according to the present possibilities, both surgical and sclerotic. A wide review of the literature underlines a high rate of relapses and persistence of the disease (with a percentage from 10 to and 10%) following the two most used technique: retrograde sclerotic therapy under radioscopic control and surgical retroperitoneal or inguinal ligature of the internal spermatic vein; this technique was preferred by us until 1997. The percentage of failures, high with reference to the benign form of the disease (over 10% in our series of more than 100 patients submitted to clinical and flow-meter examinations) let the authors suggest a combined and simultaneous operation of ligature both internal and external of the spermatic vein at the level of the internal inguinal ring. Anatomical reasons confirm the opportunity of this procedure since the involvement of the system of the external spermatic vein is present in about the 20% of the cases of idiopathic varicocele in accordance with various flebografic studies. The possibility of escape through the external spermatic vein is eliminated in the case in which such vessel is preserved, and it seems frequent above all in 3rd degree idiopathic varicocele where many anastomotic vessels between the two systems are present. This procedure can be made both in general or local anaesthesia, it doesn't involve postoperative hospital stay and present the same acceptable postoperative complication of other proposed operations. The laparoscopic treatment even if easily performed at the level of the internal inguinal ring, doesn't seem justified for the higher cost and equal compliance for the patient. Besides, it is not possible to proceed laparoscopically under local anaesthesia.

[Bilateral aneurysm of the popliteal vein. A case report and review of the literature]

We report a case of a 86-year-old woman, with a 1-year history of pain during walking and standing; a duplex scanning of the popliteal fossa was performed bilaterally. We pointed out the presence of a bilateral popliteal vein aneurysm, partially thrombosed. She was treated only with oral anticoaugulant therapy, because of her age. Venous aneurysms are quite rare and are considered to be true when all three cell layers are present in the vessel wall; bilateral popliteal venous aneurysm is very rare and only one case was previously described. This report describes, moreover, with a large review of the world literature, histologic features and diagnostics and therapeutic choices.

[Primary hyperaldosteronism caused by monolateral adrenal hyperplasia]

We have reported two patients with unilateral adrenal hyperplasia as a rare cause of primary aldosteronism, and discussed the literature on this subject. When diagnosed by NMR-CT imaging and selective sampling from adrenal veins, the treatment of this disorder appears to be surgical. Whether its pathogenesis is related to the more common varieties of primary aldosteronism is open to speculation according to metabolic findings.