Economic Evaluation of Three BRAF + MEK Inhibitors for the Treatment of Advanced Unresectable Melanoma With BRAF Mutation From a US Payer Perspective

BACKGROUND

The combinations of BRAF + MEK inhibitors-encorafenib (ENC) + binimetinib (BIN), cobimetinib (COB) + vemurafenib (VEM), and dabrafenib (DAB) + trametinib (TRA)-are recommended for the treatment of BRAF-mutated advanced melanoma.

OBJECTIVE

To assess the cost-effectiveness and cost-utility of ENC + BIN versus COB + VEM versus DAB + TRA from a US payer perspective.

METHODS

A Markov model was constructed to simulate a hypothetical cohort over a time horizon of 10 years. The overall survival (OS) and progression-free survival (PFS) curves were independently digitized from a randomized controlled trial for ENC + BIN and fitted using R software. Published and indirectly estimated hazard ratios were used to fit OS and PFS curves for COB + VEM and DAB + TRA. Costs, life-year gains, and quality-adjusted life years (QALYs) associated with the 3 treatment combinations were estimated. A base case analysis and probabilistic sensitivity analysis (PSA) were conducted to estimate the incremental cost-utility ratio (ICUR). A discount rate of 3.5% was applied on cost and outcomes.

RESULTS

The ENC + BIN versus COB + VEM comparison was associated with an ICUR of $656 233 per QALY gained. The ENC + BIN versus DAB + TRA comparison was associated with an ICUR of $3 135 269 per QALY gained. The DAB + TRA combination dominated COB + VEM. The base case analysis estimates were confirmed by the PSA estimates. ENC + BIN was the most cost-effective combination at a high willingness-to-pay (WTP) threshold of $573 000 per QALY and $1.5 million/QALY when compared to COB + VEM and DAB + TRA, respectively.

CONCLUSION AND RELEVANCE

Given current prices and acceptable WTP thresholds, our study suggests that DAB + TRA is the optimum treatment. In this study, ENC + BIN was cost-effective only at a very high WTP per QALY threshold.

The status and preparation for the next decade of biosimilars in the Middle Eastern and North African region

INTRODUCTION

Little is known about the status and the future potential of biosimilars in the Middle East and North Africa (MENA) region.

AREAS COVERED

This perspective provides insights into the current regulatory landscape of some MENA countries, currently available biosimilars, the potential of biosimilars in the next decade, and challenges to overcome.

EXPERT OPINION

Given the economic and demographic heterogeneity across the MENA countries, biosimilars could reduce significant economic unmet needs in these countries. In the next decade, biosimilars may witness higher approval rates and market share over their originators in the MENA countries. We argue that the regulatory bodies in the MENA countries should adopt the new policies of the FDA, the EMA, and the WHO, that aim to ease the biosimilar approval process. These policies are to adopt technology in the process of approval; engage health technology assessment bodies in price assessment; provide educational materials to increase awareness among providers, patients, and payers. Further, MENA countries should upgrade the external-reference pricing systems to more sophisticated ones that consider the heterogeneity in economics and needs.

Cost-effectiveness of palonosetron and dexamethasone-based triple and quadruple regimens in preventing highly emetogenic chemotherapy-induced nausea and vomiting

OBJECTIVE

Cost-effectiveness analyses that consider all currently used antiemetics in the case of emetogenic chemotherapy-induced nausea and vomiting (CINV) have not been performed yet. We aim to compare the cost-effectiveness of olanzapine (OLA), or/and neurokinin-1 receptor antagonists (NK-1-RAs), in combination with palonosetron (PAL) and dexamethasone (DEX) in preventing highly emetogenic CINV.

METHODS

Two decision analytic models were constructed. The first model was based on overall complete response (CR); the second model was based on rate of absence of nausea. Four antiemetic regimens PAL + DEX, NK-1-RAs + PAL + DEX, OLA + PAL + DEX, and PAL + NK-1-RA + DEX + OLA were compared in terms of cost, overall CR and rate of absence of nausea. Base case incremental cost-effectiveness ratio (ICER) estimates were calculated. The study was from the US payer perspective.

RESULTS

In terms of CR, the PAL + NK-1-RA + DEX + OLA was associated with the highest gains in the percentage of CR among all treatment regimens at base case ICERs of $4220 versus PAL + DEX, $4656 versus NK-1-RA + PAL + DEX, $16,471 versus OLA + PAL + DEX. In term of rate of absence of nausea, the PAL + NK-1-RA + DEX + OLA was associated with the highest rate of absence of nausea among all the treatment regimens at base case ICERs of $2291 versus PAL + DEX, $1304 versus NK-1-RA + PAL + DEX, $2657 versus OLA + PAL + DEX.

CONCLUSION

from an economic perspective, our study revealed that whether to use overall CR or/and rate of absence of nausea as determinants in the antiemetic decision for the CINV patients, the CR-based-, and rate of absence of nausea-based cost-effectiveness analyses, showed negotiable ICER estimates for the treatment PAL + NK-1-RA + DEX + OLA over the combinations PAL + DEX, NK-1-RA + PAL + DEX, and OLA + PAL + DEX regimens.

Gaps in pharmaceutical care for patients with mental health issues: A cross-sectional study

Background

Mental health issues such as depression and anxiety are often underdiagnosed and undertreated. Medications are a primary method of managing mental health problems, and pharmacists therefore have a vital role in supporting patients and providing them with information about the safety and efficacy of mental health medications. However, the potential role of pharmacists in managing mental health issues in Jordan has not been well established.

Aim

This study aimed to assess Jordanian pharmacists’ attitudes and actual practices related to the provision of mental health services.

Method

This was an exploratory cross-sectional study that used a self-report questionnaire among a convenience sample of 347 pharmacists in Amman, the capital of Jordan.

Results

The participating pharmacists had positive attitudes towards providing care for patients with mental health problems. However, their actual practices did not resonate with their enthusiasm, particularly in terms of the long-term follow-up of disease symptoms and medication side effects and adherence. The participating pharmacists showed an eagerness to collaborate with their colleagues, but their level of actual cooperation was lower than desired. The most reported barrier to providing care for patients with mental health problems was the lack of education on mental health issues (71.5%), followed by the lack of privacy in pharmacy settings (53.9%).

Conclusion

To be effectively involved in the provision of care to mental health patients, pharmacists should receive adequate education/training related to mental health issues, and pharmacies should be redesigned to provide private areas for patient counseling.

Perspectives of the community in the developing countries toward telemedicine and pharmaceutical care during the COVID-19 pandemic

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Evaluating Six Commercially Available Closed-System Drug-Transfer Devices Against NIOSH's 2015 Draft Vapor Protocol

Purpose: In 2015, the National Institute for Occupational Safety and Health (NIOSH) published a draft vapor containment protocol to quantitatively evaluate combined liquid, aerosol, and vapor containment performance of commercially available closed-system drug-transfer devices (CSTDs) that claim to be effective for gas/vapor containment within a controlled test environment. Until the release of this proposed protocol, no standard method for evaluating airtightness of CSTDs existed. The aim of this study was to evaluate six commercially available CSTDs utilizing NIOSH draft protocol methodology to evaluate vapor containment under a robust vapor challenge. Methods: In this study, six commercially available CSTDs were tested utilizing draft NIOSH vapor containment protocol methodology to simulate drug compounding and administration using 70% isopropyl alcohol (IPA) as the challenge agent. All device manipulations were carried out in an enclosed test chamber. A Miran sapphIRe gas analyzer was used to detect IPA vapor levels that escaped the device. Study test included the two tasks designated by the NIOSH protocol, with additional steps added to the evaluation. Tasks were repeated 10 times for each device. Results: Only three of the six tested CSTDs (Equashield®, HALO®, and PhaSealTM) had an average IPA vapor release below the quantifiable performance threshold (1.0 ppm) for all tasks performed. This value was selected by NIOSH to represent the performance threshold for successful containment. The remaining three CSTDs had vapor release above 1 ppm at various times during the IPA manipulation process. Conclusion: Equashield®, HALO®, and PhaSealTM devices tested met the 2015 NIOSH protocol quantifiable performance threshold, functioning as a truly closed system. Quantifiable effective data may be useful in product selection.

Establishing the six-month resource utilization and cost-of-care for the treatment of first-line metastatic BRAF (V600) melanoma with combination BRAF and MEK inhibitors

e19396

Background: Comparative data on cancer therapy health care resource utilization (HCRU) and associated cost will be helpful as value-based healthcare moves forward. BRAF & MEK inhibitor combinations are considered first-line treatment for BRAF (V-600) metastatic melanoma (MM), although head-to-head trials are lacking. We aimed to establish the real-world HCRU and 6-month (mo) cost-of-care in V-600 MM treated with BRAF & MEK inhibitor therapy. Methods: A single data team in 2018 performed a multicenter, retrospective chart audit of adult patients with BRAF V-600 MM. Four institutions from across the US with patients who had received either dabrafenib + Trametinib (DT) or vemurafenib + cobimetinib (VC) were enrolled. In the most recent 12 mo period, data was captured from the start of therapy for 6 mo or until therapy was stopped. Dose change or stoppage was accessed for cause (toxicity, disease, death, other). Variables included hospitalization, emergency room (ER), all clinic visits (routine + extra), scans, labs, and treatment drug (AWP). Medicare reimbursed rates were applied for cost estimates. Utilization and costs were measured on per patient per month (PPPM) bases and the total cost over 6 mo for each combination. Results: Of the 42 patients included, 34 and 8 were initiated on DT and VC, respectively. Proportions of patients with extra clinic visits and hospital admissions were 79%, 15% and 75%, 13%, respectively for DT and VC. PPPM hospitalization was the lowest among the resources utilized 0.24 for DT and 0.17 for VC. A higher proportion of VC patients (75%) had a dose reduction due to drug toxicity compared with 29% of patients treated with DT (P < 0.05). Discontinuation rates were the same between both combinations (0.26). 32 patients had completed 6 mo of treatment (26 DT and 6 VC). For those DT, the mean total costs including drug and the mean monthly total costs were $157,253 and $26,209 compared to $107,240 and $17,873 for VC, respectively. The mean total costs for hospitalization were $10,562 for DT and $7,456 for VC. The mean total costs for the drug were $145,012 for DT and $97,924 for VC. Conclusions: The 6-month total cost-of-care for the treatment of first-line V-600 MM with DT was $157,253 and $107,240 for VC, mostly attributable to drug cost. In a value-based healthcare system, total 6-month cost-of-care may help distinguish between equally effective regimens.