Cost-effectiveness and healthcare budget impact in Italy of inhaled corticosteroids and bronchodilators for severe and very severe COPD patients

Current practice guidelines for the treatment of COPD recommend the use of combined inhaled corticosteroids and long-acting bronchodilators in severe and very severe patients (GOLD stages III and IV). The aim of this study was to evaluate, through a simulation model, the economic consequences of this recommendation in Italy. We developed a cost-effectiveness analysis (CEA) on five alternative therapeutic strategies (salmeterol/fluticasone, SF; formoterol! budesonide, FB; salmeterol alone, S; fluticasone alone, F; control, C). Published data on the Italian COPD population and efficacy data from international reference trials were fitted in a disease progression model based on a Markov chain representing severity stages and death. The yearly total direct costs of treating COPD patients in Italy was estimated at approximately Euro 7 billion, with a mean cost per patient per year of around Euro 2450. Mean survival of the cohort is 11.5 years. The C and F strategies were dominated (ie, are associated with worse outcomes and higher costs) by all alternatives. SF and FB were the most effective strategies, with a slight clinical superiority of SF, but they were also marginally more expensive than S. Incremental cost-effectiveness of SF vs S was Euro 679.5 per avoided exacerbation and Euro 3.3 per symptom-free day. Compared with current practice, the recommended use of combined inhaled corticosteroids and long-acting bronchodilators for severe and very severe COPD patients has the potential for improving clinical outcomes without increasing healthcare costs.

Topical metronidazole and clotrimazole in the treatment of vulvo-vaginal infections during pregnancy

Vulvo-vaginal infections are the most common gynaecological pathologies seen in clinical practice. While being predominantly benign, although disturbing, in non pregnant women, their presence during pregnancy has been associated with peri-natal and obstetric complications. The opportunity to prevent these adverse outcomes, especially prematurity and low birth weight, has to be cautiously balanced against the potential to induce fetal toxicity, inherently related to the continuous exchanges among maternal and fetal blood that occurs in the placenta. In this paper, a brief overview of the evidence regarding efficacy, safety and utility during pregnancy of topical clotrimazole and metronidazole, whose combined spectrum covers the great majority of the involved pathogens, is provided. These antimicrobials, especially when applied topically, are highly effective and have been used in pregnant women for many years without evidence of adverse outcomes; in conclusion it appears that they hold an adequate risk-to-benefit ratio and represent valid therapeutic options in the treatment of vulvo-vaginal infections during pregnancy.