Economic impact of switching from metoprolol to nebivolol for hypertension treatment: a retrospective database analysis

OBJECTIVE

To estimate the real-world economic impact of switching hypertensive patients from metoprolol, a commonly prescribed, generic, non-vasodilatory β1-blocker, to nebivolol, a branded-protected vasodilatory β1-blocker.

METHODS

Retrospective analysis with a pre-post study design was conducted using the MarketScan database (2007-2011). Hypertensive patients continuously treated with metoprolol for ≥6 months (pre-period) and then switched to nebivolol for ≥6 months (post-period) were identified. The index date for switching was defined as the first nebivolol dispensing date. Data were collected for the two 6-month periods pre- and post-switching. Monthly healthcare resource utilization and healthcare costs pre- and post-switching were calculated and compared using Wilcoxon test and paired t-test. Medical costs at different years were inflated to the 2011 dollar.

RESULTS

In total, 2259 patients (mean age: 60 years; male: 52%; cardiovascular [CV] disease: 37%) met the selection criteria. Switching to nebivolol was associated with statistically significant reductions in the number of all-cause hospitalization (-33%; p < 0.01), CV-related hospitalizations (-60%; p < 0.01), and outpatient visits (-7%; p < 0.01). Monthly inpatient costs were reduced by $111 (p < 0.01), while monthly drug costs increased by $52 (p < 0.01). No statistically significant differences were found in overall costs and costs of outpatient or ER visits. Sensitivity analyses, conducted using various lengths of medication exposure, controlling for spill-over effect or excluding patients with compelling indications for metoprolol, all found some level of reduction in resource utilization and no significant difference in overall healthcare costs.

CONCLUSIONS

This real-world study suggests that switching from metoprolol to nebivolol is associated with an increase in medication costs and significant reductions in hospitalizations and outpatient visits upon switching, resulting in an overall neutral effect on healthcare costs. These results may be interpreted with caution due to lack of a comparator group and confounding control caused by design and limitations inherent in insurance claims data.

Use of Natural Gums and Cellulose Derivatives in Production of Sustained Release Metoprolol Tablets

Metoprolol tartrate sustained-release tablets (100 mg) were prepared using xanthan/guar gums and also hydroxypropyl methyl cellulose (HPMC) carboxymethyl-Cellulose (CMC) polymers by direct compression method. Physical characteristics of the tablets and water uptake in addition to their dissolution profiles were compared with standard (Lopressor SR) tablets. Dissolution test was performed in the phosphate buffer solution (pH 6.8) and the samples were analyzed spectrophotometerically in 275.7 nm. Dissolution studies showed that formulations containing 100 and 80% of HPMC, 100% of guar, and 20% of xanthan followed the Higuchi model, while those containing 60 and 40% HPMC and 100 and 80% xanthan followed a zero-order model. The tablets with 40% xanthen followed a Hixon-Crowell model. In cellulose derivatives the highest MDT and dissolution efficiency until 8 hr (DE8%) belonged to tablets with 40% HPMC, increasing the amount of CMC decreased the drug release rate, and formulations containing 60 and 40% of HPMC had the USP dissolution standards. While, in the gum formulations, the highest mean dissolution time and the lowest DE(8)% belonged to tablets with 100% xanthan, increasing the xanthan decreased the release rate of metoprolol, and formulations containing 80 and 100% xanthan had the USP dissolution standards. Results showed that natural gums are suitable for production of sustained-release tablets of metoprolol.

Medication costs as a primary cause of nonadherence in the elderly

Many elderly enrolling in the Medicare Part D prescription drug benefit, which began January 1, 2006, have low annual incomes and few countable assets. Although some are eligible for special assistance to pay for prescription medications, many others will still have significant out-of-pocket expenses while enrolled. The inability to pay for medications is an important cause of nonadherence in the elderly and has been associated with an increase in adverse drug events, acute hospitalizations, and nursing home admissions. This case describes a 77-year-old woman residing in a retirement community who was failing to respond to drug therapy for her hypertension and diabetes. The physician was unaware of her inability to pay for medications, and the patient was too embarrassed to discuss the issue. The case demonstrates some of the techniques that a pharmacist can use to adjust a patient's medication regimen to reduce the cost load, improve adherence, and maintain treatment goals.

Economic Implications of Extended-Release Metoprolol Succinate for Heart Failure in the MERIT-HF Trial: A US Perspective of the MERIT-HF Trial

BACKGROUND

The MERIT-HF trial demonstrated improved survival and fewer hospitalizations for worsening heart failure with extended-release (ER) metoprolol succinate in patients with heart failure. This study sought to estimate the economic implications of this trial from a US perspective.

METHODS AND RESULTS

A discrete event simulation was developed to examine the course of patients with heart failure. Characteristics of the population modeled, probabilities of hospitalization and death with standard therapy, and risk reductions with ER metoprolol succinate were obtained from Metoprolol CR/XL Randomized Intervention Trial in Chronic Heart Failure (MERIT-HF) and evaluated in weekly cycles. Direct medical costs were estimated from US databases in 2001 US dollars. Uncertainty in inputs was incorporated and analyses were carried out to estimate events prevented total and net costs. The model predicts that ER metoprolol succinate will prevent approximately 7 deaths and 15 hospitalizations from heart failure per 100 patients over 2 years. Compared with standard therapy alone, this translates to a cost reduction between $395 and $1112 per patient, depending on whether the costs of hospitalizations for other causes are included. Savings were maintained in 90% of the simulations.

CONCLUSION

This analysis predicts that the positive effect of ER metoprolol succinate on mortality and morbidity demonstrated in MERIT-HF leads to substantial savings.

[Congestive heart failure in Spain: cost-effectiveness and cost-benefit analyses of treatment with beta-blockers]

OBJECTIVE

Beta-blockers (BB) have proven to be effective in the treatment of congestive heart failure (CHF). This study is an economic analysis for the addition of BB to standard treatment of CHF.

PATIENTS AND METHOD

Randomized, double-blinded controlled studies are included, with 1,647 patients treated with bisoprolol, 3,034 treated with carvedilol, 2,432 treated with metoprolol, and 6,807 treated with placebo. Direct costs of BB treatment and of every hospitalization episode are assessed. Cost-effectiveness is assessed as cost in euros by prevented death, and cost-benefit as the difference between hospitalization costs and BB costs. The study is conducted from the perspective of a third-party payer.

RESULTS

Two studies with bisoprolol, six with carvedilol, and five with metoprolol are included, with an average follow-up of 13.5 months. Carvedilol prevents 5.07% of deaths per year of treatment and is more effective than bisoprolol (3.82% of avoided deaths) and metoprolol (3.03%). Cost-effectiveness ratio (cost for every prevented death and year) was 10,832 euros for bisoprolol, 17,516 euros for carvedilol and 16,664 euros for metoprolol. Incremental cost-effectiveness ratio for carvedilol ranges between 12,631 euros and 86,610 euros for life saved. All BB generate costs saving for hospitalization but only bisoprolol provides a net profit. Benefit-cost index is 1.13 for bisoprolol, 0.26 for carvedilol and 0.59 for metoprolol.

CONCLUSIONS

Use of BB in the treatment of CHF is an effective and cost-effective alternative. Carvedilol is the most effective alternative, and bisoprolol the most cost-effective alternative and the drug with greater benefit-cost index.

Cost-effectiveness of differing perioperative beta-blockade strategies in vascular surgery patients

OBJECTIVES

To determine the incremental value of different strategies of both oral and intravenous beta-blockade during the perioperative period in high-risk vascular patients in reducing costs and improving outcomes.

DESIGN

Decision analytic model incorporating costs from provider's perspective

INTERVENTIONS

Five perioperative strategies in patients undergoing abdominal aortic aneurysm surgery: (1). no routine beta-blockade, (2). preoperative oral bisoprolol for 7 days followed by perioperative intravenous metoprolol and oral bisoprolol based on preoperative titration, (3). immediate preoperative atenolol with postoperative intravenous then oral atenolol, (4). intraoperative esmolol and postoperative intravenous then oral atenolol, and (5). intraoperative and 18 hours of postoperative esmolol then atenolol.

MEASUREMENTS AND MAIN RESULTS

Perioperative death was associated with a net increase of US dollars 21909 in charges to Medicare, whereas sustaining a perioperative myocardial infarction was associated with a net increase in charges of US dollars 15000. There is a net hospital saving of US dollars 500 using a strategy of titration of an oral beta-blocker medication for a minimum of 7 days, with a net increase in efficacy of 0.0304. All of the strategies involving acute perioperative blockade were associated with a net cost savings and increase in efficacy, although less than the strategy involving preoperative oral titration.

CONCLUSION

Perioperative beta-blockade is both cost effective as well as efficacious from a short-term provider perspective. The optimal strategy of treatment for patients who do not present to surgery already on beta-blockers requires further study, although all strategies save money even accounting for pharmaceutical costs.

In heart failure, all beta-blockers are not necessarily equal

The Carvedilol or Metoprolol European Trial (COMET; Lancet 2003; 362:7-13) found that in patients with heart failure, survival appears to be better with carvedilol than with immediate-release metoprolol tartrate. Whether the target doses used were equivalent (carvedilol 25 mg twice daily vs metoprolol tartrate 50 mg twice daily) has been debated, but the COMET trial shows that drugs in the same class do not necessarily have the same effects. Given the overwhelming evidence of the benefit of carvedilol, metoprolol succinate, and bisoprolol in patients with heart failure, we should all strive to increase the use of these drugs in appropriate doses.

Double-blind, placebo-controlled, randomized trial of prophylactic metoprolol for reduction of hospital length of stay after heart surgery: the beta-Blocker Length Of Stay (BLOS) study

BACKGROUND

Atrial fibrillation (AF) is a common complication of heart surgery. Previous studies have shown that there is an association between postoperative AF and prolongation of hospital length of stay. No previous trials have been primarily directed at demonstrating that the use of drugs that prevent AF would shorten length of stay and reduce the costs of postoperative care.

METHODS

A randomized, double-blind, placebo-controlled trial of metoprolol was performed in patients immediately after nonemergent heart surgery. Metoprolol was given orally at a dose of 100 mg per day after the patient's arrival in the intensive care unit until hospital discharge or 14 days, whichever was sooner. This dose was increased to 150 mg per day after the enrollment of 411 patients. The primary outcome measure of the study was hospital length of stay from admission to intensive care unit until hospital discharge. There were 1000 patients enrolled, evenly distributed to the metoprolol and placebo groups.

RESULTS

There was a 20% reduction in the risk of AF developing with metoprolol, from 39% of patients to 31% of patients (P =.01). There was no effect of treatment on hospital length of stay, which was 152 +/- 61 hours for placebo and 155 +/- 90 hours for metoprolol (P = 0.79). The cost of postoperative care in the 2 treatment groups was similar.

CONCLUSION

Prophylactic metoprolol reduces the risk of AF after heart surgery. It does not reduce hospital length of stay. Although it is cost effective for the reduction of AF, it did not reduce the overall cost of care.

Reimbursement claims analysis of outcomes with carvedilol and metoprolol

OBJECTIVE

To compare resource use and costs in heart failure (HF) patients receiving metoprolol, a selective beta1-receptor blocker, with carvedilol, which blocks beta1-, beta2-, and alpha1-adrenergic receptors, by use of a retrospective reimbursement-claims analysis.

METHODS

Resource use and cost data were extracted for patients diagnosed with HF and treated with carvedilol or metoprolol for 6 months after the initiation of the respective therapy, by use of claims submitted to 6 healthcare plans. A modified Charlson index was used to assess comorbidity. Stepwise logistic regression was used to measure the influence of treatment on hospitalization.

RESULTS

Claims from 139 carvedilol and 106 metoprolol patients showed that carvedilol patients experienced significantly fewer total hospitalizations (36.0% vs. 62.3%, respectively; p < 0.001) and emergency department visits (23.7% vs. 42.5%, respectively; p = 0.002) and a trend for fewer HF-related (7.9% vs. 14.2%, respectively; NS) and cardiac-related hospitalizations (15.1% vs. 24.5%, respectively; NS). Treatment with carvedilol was associated with a significant decrease in the risk of any hospitalization (adjusted odds ratio 0.35, 95% CI 0.20 to 0.63; p <0.001). Higher pharmacy costs (mean $1677 vs. $1322; p <0.001) and lower total costs (mean $8100 vs. $14475; p = 0.025) were observed in carvedilol-treated compared with metoprolol-treated patients, respectively.

CONCLUSIONS

Compared with metoprolol, the more comprehensive adrenergic blockade achieved with carvedilol may translate into greater clinical benefits in patients with HF. Despite higher pharmacy costs, lower total costs were observed in carvedilol-treated patients.

Cost-effectiveness of beta-blocker therapy with metoprolol or with carvedilol for treatment of heart failure in Canada

OBJECTIVE

The purpose of this study was to estimate the cost-effectiveness of beta-blocker therapy with either metoprolol or carvedilol in addition to conventional therapy for patients with heart failure (HF) in Canada.

DESIGN

A Markov simulation was used to estimate the costs and life expectancy for treating patients with conventional therapy alone and with the addition of metoprolol or carvedilol. Although carvedilol has been marketed in Canada since 1999, metoprolol succinate has yet to be marketed there, so the price is unknown. Therefore we input a Canadian price based on the price ratio of the 2 drugs in the United States.

RESULTS

For subjects aged 60 years at HF onset, the expected years of life are 4.53 years for those treated with conventional therapy alone, 5.70 years for those who receive conventional therapy plus metoprolol, and 6.21 years for those who receive conventional therapy plus carvedilol. The expected costs (in 1999 Canadian dollars) are $8,989, $13,833, and $18,114, respectively. This yields incremental cost-effectiveness ratios (ICERs) for metoprolol relative to conventional therapy alone of $4,140 per life-year gained, and for carvedilol relative to metoprolol, the ICER is $8,394 per life-year gained.

CONCLUSIONS

In addition to conventional therapy with furosemide and angiotensin converting enzyme inhibitors, treatment with either metoprolol or carvedilol confers a survival benefit that is attractive from a cost-effectiveness point of view. Until better information becomes available, it is not possible to distinguish between the two beta-blockers on the basis of cost-effectiveness. This means that the choice of beta-blockers for HF should be based largely on clinical considerations because both beta-blockers prolong life at relatively low cost.

Economic impact of beta blockade in heart failure

We reviewed the literature on clinical trials of beta-adrenergic blockade for treatment of heart failure, seeking evidence of reductions in hospital admissions. To analyze the economic implications of six clinical trials, we developed a stochastic cost model to generate estimates of total medical costs resulting from heart failure and related causes. The model includes inpatient, outpatient, and professional cost estimates based on Medicare claims data, and it is driven by traditional endpoint statistics reported in the clinical trial literature. It provides a common framework for comparing cost effectiveness across clinical trials in the absence of detailed cost information collected in the trial. The incremental expected cost per year of life saved is $3,300 for bisoprolol, $2,500 for metoprolol, and $6,700 for carvedilol. The cost per year of life saved for each compound is well below accepted standards for cost effectiveness. These results are sensitive to the cost of drug therapy and the relative mortality rate for the experimental group. For example, if the relative mortality rate of the experimental group were to increase from the reported 40% to 82%, and if the annual cost of the drug were to decrease from $2,000 to $500, then we estimate that carvedilol would break even and the cost per year of life saved would drop to zero. Whether beta-blocker therapy, as assumed, sustains its differential effectiveness in terms of relative mortality risk beyond the study duration has not been demonstrated.

Cost-effectiveness of felodipine-metoprolol (Logimax) and enalapril in the treatment of hypertension

We present results from a Swedish retrospective cost-effectiveness analysis of felodipine-metoprolol (Logimax) and enalapril in hypertension. In the 8-week trial, the average reduction of diastolic blood pressure (DBP) and the share of patients reaching target DBP were both significantly greater in the felodipine-metoprolol group. Cost of treatment (costs of drugs and physician visits) was somewhat higher in the felodipine-metoprolol group. After 8 weeks, an extra 4.8 mmHg reduction and an additional 22% of patients reaching target DBP were achieved with felodipine-metoprolol at the extra cost of SEK 19 (Swedish kronor, $US I=SEK 7.90). The incremental cost per mmHg reduction and per patient reaching target DBP was calculated at SEK 4 and SEK 86, respectively. Average cost-effectiveness ratios showed that the costs per mmHg reduction and per patient reaching target DBP after 8 weeks were 40 and 34% lower in the felodipine-metoprolol group, respectively. In conclusion, felodipine-metoprolol is cost-effective in the treatment of hypertension.

Metoprolol: a pharmacoeconomic and quality-of-life evaluation of its use in hypertension, post-myocardial infarction and dilated cardiomyopathy

Metoprolol is a beta 1-selective adrenoceptor antagonist that is widely used in several indications. A recent investigation has also highlighted a potential role for metoprolol in selected patients with idiopathic dilated cardiomyopathy. Pharmacoeconomic and quality-of-life data for metoprolol are limited to the areas of hypertension, post-myocardial infarction and idiopathic dilated cardiomyopathy. In these settings, metoprolol has shown beneficial effects on morbidity and mortality, or closely-related end-points. Controlled release formulations offer the potential to maximise the confirmed antihypertensive benefits of metoprolol by maintaining clinically effective plasma drug concentrations within a narrow range over a 24-hour interval between doses. Recent data support the use of controlled release metoprolol at the low dose of 50 mg/day. Metoprolol is at least as effective as many other antihypertensive drugs, although compared with thiazide diuretics at relatively high doses in the MAPHY (Metoprolol Atherosclerosis Prevention in Hypertensives) trial, metoprolol was associated with a more favourable effect on mortality. Pharmacoeconomic analysis, also based on the MAPHY trial, indicates that metoprolol is more cost effective than high dose thiazide diuretics in middle-aged men with mild to moderate hypertension. However, the advantage for beta-blockade in this trial is not supported by results of other studies, and the applicability of these data to current medical practice using lower thiazide doses is therefore questionable. Quality of life in patients with mild to moderate hypertension did not deteriorate in most investigations with metoprolol. Furthermore, quality of life was similar for controlled release metoprolol and atenolol. With conventional/matrix-based sustained release metoprolol, quality of life was less satisfactory than with lisinopril but was only marginally different from that with diltiazem (at lower than usual therapeutic doses). Nevertheless, these newer agents have no proven beneficial effect on mortality, and further studies are also warranted with controlled release metoprolol 50 mg/day. When administered post-myocardial infarction, conventional metoprolol was associated with significant improvements in quality of life and was cost saving over a 3-year period. Significant improvements in quality of life were also evident for metoprolol-treated patients with idiopathic dilated cardiomyopathy. In summary, available data support the continued extensive usage of metoprolol as treatment for hypertension and as therapy post-myocardial infarction. Pharmacoeconomic data supporting an advantage for metoprolol over high dose thiazides in hypertension needs further assessment in settings reflecting usual general practice approaches to managing patients with hypertension, while differences in quality of life between metoprolol and other antihypertensive agents appear to be marginal.(ABSTRACT TRUNCATED AT 400 WORDS)

Cost-effectiveness of antihypertensive treatment: metoprolol versus thiazide diuretics

The aim of the present analysis was to calculate the cost-effectiveness of metoprolol versus thiazide diuretics in middle-aged men with mild to moderate uncomplicated hypertension. The analysis was based on the Metoprolol Atherosclerosis Prevention in Hypertensives (MAPHY) study, a randomised trial which showed a significantly lower risk for coronary events in patients taking metoprolol than in patients on thiazide diuretics. The main analysis was based on Swedish costs, but the costs were also varied in a special sensitivity analysis. Metoprolol was shown to be cost-saving compared with thiazide diuretics when both direct and indirect costs of morbidity were included. When only direct costs were included, the cost per life-year gained was $US2400. The result of the present analysis suggests that metoprolol is to be preferred to thiazide diuretics from a cost-effectiveness standpoint in the treatment of mild to moderate hypertension in middle-aged men. These findings regarding cost-effectiveness should, however, not be extrapolated to patient groups not included in the MAPHY trial.