The cost-utility of intravenous magnesium sulfate for treating asthma exacerbations in children

Intravenous Magnesium: Prompt Use for Asthma in Children Treated in the Emergency Department (IMPACT-ED): Protocol for a Multicenter Pilot Randomized Controlled Trial

BACKGROUND

Children managed for asthma in an emergency department (ED) may be less likely to be hospitalized if they receive intravenous magnesium sulfate (IVMg). Asthma guidelines recommend IVMg for severely sick children but note a lack of evidence to support this recommendation. All previous trials of IVMg in children with asthma have been too small to answer whether IVMg is effective and safe. A few major questions remain about IVMg. First, it has not been tested early in the course of ED treatment, when the impact on hospitalization would be greatest. Second, the clinical impact of hypotension, a known adverse effect of IVMg, has not been well characterized in previous research. Third, no trials have compared different IVMg doses or serial serum magnesium (total and ionized) concentrations to optimize dosing, so the most effective dose is unknown. A large, conclusive, randomized, placebo-controlled clinical trial of IVMg might be challenging due to the need to enroll and complete study procedures quickly, a lack of understanding of blood pressure changes after IVMg, and a lack of pharmacologic information to guide the optimal doses of IVMg to be tested. Therefore, a pilot study to inform the above gaps is warranted before conducting a definitive trial.

OBJECTIVE

The objectives of this study are to (1) demonstrate the feasibility of enrolling children with severe acute asthma in the ED in a multicenter, randomized controlled trial of a placebo, low-dose IVMg, or high-dose IVMg; (2) demonstrate the feasibility of timely delivery of study medication, assessment of blood pressure, and evaluation of adverse events in a standardized protocol; and (3) externally validate a previously constructed pharmacokinetic model and develop a combined pharmacokinetic/pharmacodynamic model for IVMg using magnesium (total and ionized) serum concentrations and their correlation with measures of efficacy and safety.

METHODS

This pilot trial tests procedures and gathers information to plan a definitive trial. The pilot trial will enroll as many as 90 children across 3 sites, randomize each child to 1 of 3 study arms, measure blood pressure frequently, and collect 3 blood samples from each participant with corresponding clinical asthma scores.

RESULTS

The project was funded by the National Heart, Lung, and Blood Institute (1 R34HL152047-2) in March 2022. Enrollment began in September 2022, and 43 children have been enrolled as of April 2023. We will submit the results for publication in late 2023.

CONCLUSIONS

The results of this study will guide the planning of a large, definitive, multicenter trial powered to evaluate if IVMg reduces hospitalization. Blood pressure measurements will inform a monitoring plan for the larger trial, and blood samples and asthma scores will be used to validate pharmacologic models to select the optimal dose of IVMg to be evaluated in the definitive trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05166811; https://clinicaltrials.gov/ct2/show/NCT05166811.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48302.

Comparison of three alternatives for the management of moderate asthma in children aged 6-11 years: a cost-utility analysis

BACKGROUND

Recent asthma guidelines for children 6-11 years with persistent asthma advocate three alternatives: SMART (budesonide/formoterol 80/4.5 mcg qd plus additional doses as needed), fixed combination of budesonide/formoterol, and fixed-dose budesonide. Concerns have arisen as to which of the proposed alternatives has the best possible cost-effectiveness profile. This study aimed to assess the health and economic consequences of SMART, fixed combination, and fixed-dose budesonide therapy in children 6-11 years old with persistent asthma.

METHODS

A probabilistic Markov model was created to estimate the cost and quality-adjusted life-years (QALYs) of patients with persistent asthma. Total costs and QALYs of SMART, fixed combination, and fixed-dose budesonide therapy were calculated over a time horizon of 6 years. Multiple sensitivity analyses were conducted.

RESULTS

The mean QALY per patient was 0.57 and 0.56 QALYs per patient per year of SMART and fixed combination and 0,52 with fixed-dose budesonide. The total mean of discounted costs per patient per cycle were US$111 for SMART, US$133 for fixed combination, and US$67 for fixed-dose budesonide. The net monetary benefit of SMART was US$12,549, US$12278 for fixed combination, and US$11,380 for fixed-dose budesonide.

CONCLUSION

Our study showed that SMART was more cost-effective than fixed combination and fixed-dose budesonide. These findings complement and support the GINA 2021 and National Asthma Education and Prevention Program asthma guideline recommendations for use of inhaled corticosteroids-formoterol in children 6-11 years old with persistent asthma.

Cost-Utility of Continuous Positive Airway Pressure for Respiratory Distress in Preterm Infants in a Middle-Income Country

OBJECTIVES

Despite the increased popularity of continuous positive airway pressure (CPAP) for preterm infants with respiratory distress, there is still uncertainty about whether the additional costs of this device justify the clinical benefits provided. This study aims to evaluate the cost-utility of CPAP in spontaneously breathing preterm infants with respiratory distress.

METHODS

Using a decision tree model, we estimated the cost and quality-adjusted life-years (QALYs) associated with CPAP and supplemental oxygen alone by headbox or low-flow nasal cannula (SO). The model was analyzed probabilistically, and a value of information analysis was conducted to inform the value of conducting further research to reduce current uncertainties in the evidence base. Cost-effectiveness was evaluated at a willingness-to-pay value of US$5180.

RESULTS

The mean incremental cost of CPAP versus SO was US$600. The mean incremental benefit of CPAP versus SO was 0.04 QALY. The expected incremental cost per QALY was estimated at US$13 172. The mean incremental net monetary benefit was US$-324 with a 95% credible interval of US$-536 to US$-201. The overall expected value of perfect information per person affected by the decision was estimated to be US$2346.

CONCLUSIONS

Compared with SO, the use of CPAP in spontaneously breathing preterm infants with respiratory distress is not cost-effective in Colombia. Evidence should continue to be generated with real-life effectiveness data and economic evaluations in other countries to confirm our findings.

Systematic review and cost-utility of high flow nasal cannula versus continuous positive airway pressure in children with acute severe or moderate bronchiolitis in Colombia

BACKGROUND

Nasal Continuous Positive Airway Pressure (CPAP) and High-Flow Nasal Cannula (HFNC) have emerged as alternatives to orotracheal intubation and conventional invasive ventilation in patients with moderate to severe bronchiolitis. This study aims to evaluate the evidence and the cost-utility of HFNC compared to CPAP in infants with moderate-severe bronchiolitis in Colombia.

METHODS

The search includes electronic databases such as Pubmed, ScienceDirect, and Embase. Through inclusion and exclusion criteria, screen randomized controlled trials. A decision tree model was used to estimate the cost-utility of CPAP compared with HFNC in infants with moderate-severe bronchiolitis. Sensitivity analysis of transition probabilities, utilities, and cost was carried out.

RESULTS

Incorporate five studies that meet the criteria. The risk of intubation rate in the patients with CPAP is lower than HFNC (relative risk 0.62; 95% confidence interval 0.46-0.84; I2  = 0%) The base-case analysis showed that compared with HFNC, CPAP was associated with lower costs and higher quality-adjusted life years (QALYs). The expected annual cost per patient with CPAP was US$17,574 and with HFNC was US$29,421. The QALYs per person estimated with CPAP were 0.92 and with HFNC was 0.91. This position of absolute dominance of CPAP (CPAP has lower costs and higher QALYs than HFNI) makes it unnecessary to estimate the incremental cost-utility ratio.

CONCLUSIONS

CPAP is cost-effective, over the HFNC, in infants with severe-moderate bronchiolitis in Colombia. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines and should be replicated to validate their results in other countries.

Stating the obvious: intravenous magnesium sulphate should be the first parenteral bronchodilator in paediatric asthma exacerbations unresponsive to first-line therapy

What is the most appropriate second-line intravenous bronchodilator treatment when a child with a severe asthma attack is not responsive to initial inhaled therapy? The second-line treatment options for acute asthma include parenteral β₂-agonists, methylxanthine and magnesium sulphate (MgSO₄). There is a poor evidence-base to inform this decision. This review argues that intravenous MgSO₄ is the obvious treatment of choice for this situation as the initial treatment based on current knowledge.  We describe the mode of action, scope and limitations of MgSO₄, safety profile, economic impact, comparisons of the alternatives, and finally, what the guidelines say.  This review explores the suitability of intravenous MgSO₄ as a pragmatic and safe initial second-line therapy for children unresponsive to initial asthma management.

Budget Impact Analysis of Hypertonic Saline Inhalations for Infant Bronchiolitis: The Colombian National Health System Perspective

OBJECTIVES

Nebulized 3% hypertonic solution (HS) is associated with lower total cost and higher quality-adjusted life-years. Nevertheless, the expected budget impact of this drug had not been explicitly estimated. The aim of this study was to evaluate the budget impact of 3% HS in the treatment of acute bronchiolitis in Colombia.

METHODS

A budget impact analysis was performed to evaluate the potential financial impact of the use of 3% HS. The analysis considered a 4-year time horizon and a Colombian national health system perspective. The incremental budget impact was calculated by subtracting the cost of the new treatment, in which 3 % HS (added to humidified oxygen) was reimbursed, from the cost of the conventional treatment without 3 % HS (only humidified oxygen or adrenaline nebulization). Univariate 1-way sensitivity analyses were performed.

RESULTS

In the base-case analysis, the 4-year costs associated with HS and non-3% HS were estimated to be $47 792 230 and $53 312 832, respectively, indicating savings for Colombian national health system equal to $5 520 602 if HS is adopted for the routine management of patients with acute bronchiolitis. This result was robust in univariate 1-way sensitivity analysis.

CONCLUSION

HS was cost saving in emergency settings for treating infants with acute bronchiolitis. This evidence can be used by decision makers in Colombia to improve clinical practice guidelines and should be replicated to validate their results in other middle-income countries.

Budget impact analysis of high-flow nasal cannula for infant bronchiolitis: the Colombian National Health System perspective

BACKGROUND

High-flow nasal cannula is a non-invasive ventilation system that was introduced as an alternative to continuous positive airway pressure), with a marked increase in its use in pediatric care settings. However, the expected budget impact of this intervention has not been explicitly estimated. This study aimed to evaluate the budget impact of the high-flow nasal cannula for acute bronchiolitis in Colombia.

METHODS

A budget impact analysis was performed to evaluate the potential financial impact deriving from high-flow nasal cannula during 2020. The analysis considered a 5-year time horizon and Colombian National Health System perspective. The incremental budget impact was calculated by subtracting the cost of the new treatment, in which a high-flow nasal cannula is reimbursed, from the cost of the conventional treatment without a high-flow nasal cannula (supplemental oxygen through a nasal cannula up to a maximum of 2 liters per minute). Univariate one-way sensitivity analyses were performed.

RESULTS

In the base-case analysis the 5-year costs associated with high-flow nasal cannula and no- high-flow nasal cannula were estimated to be US$159,585,618 and US$172,751,689 respectively, indicating savings for Colombian National Health equal to US$13,166,071 if the high-flow nasal cannula is adopted for the routine management of patients with acute bronchiolitis. This result was robust in univariate sensitivity one-way analysis.

CONCLUSION

High-flow nasal cannula was cost-saving in emergency settings for treating infants with acute bronchiolitis. This evidence can be used by decision-makers in our country to improve clinical practice guidelines and should be replicated to validate their results in other middle-income countries.

Budget impact analysis of surfactant therapy for bronchiolitis in critically ill infants: the Colombian National Health System perspective

Background

Severe bronchiolitis requiring mechanical ventilation was associated with an absence of surfactant activity and phosphatidylglycerol, causing airway obstruction in acute bronchiolitis. Exogen surfactant in mechanically ventilated infants decreased duration of stay in the intensive care unit and had favorable effects on oxygenation and carbon dioxide removal. This study aimed to evaluate the budget impact of surfactant therapy for bronchiolitis in critically ill infants in Colombia.

Methods

Budget impact analysis was performed to estimate the economic impact of surfactant therapy (ST) for the treatment of infants with a diagnosis of bronchiolitis, requiring mechanical ventilation. The analysis considered a 4-year time horizon and Colombian National Health System perspective. The model estimated drug costs associated with current scenario using humidified oxygen or adrenaline nebulization, and new scenario adding exogen surfactant. The size of the target population was calculated using epidemiological national data. Univariate one-way sensitivity analyses and scenario analyses were performed.

Results

In the base-case analysis the 4-year costs associated to ST and no-ST were estimated to be US$ 55,188,132 and US$ 55,972,082 respectively, indicating savings for Colombian National Health equal to US$ 783,950 if ST is adopted for the routine management of patients with bronchiolitis requiring mechanical ventilation. In the one-way sensitivity analysis, only increases in the cost of the surfactant drug and cost or length of stay in the pediatric intensive unit reduce the potential savings of ST.

Conclusion

ST was cost-saving in emergency settings for treating infants with severe bronchiolitis requiring mechanical ventilation. This shift in treatment approach proved to be economically favorable in the Colombian context.

Cost-utility of use of sputum eosinophil counts to guide management in children with asthma

BACKGROUND

Tailoring asthma interventions based on sputum eosinophils are beneficial in reducing the frequency of asthma exacerbations. The routine use of sputum eosinophils in asthma in children is not uniformly adopted. The main barriers to policymakers adopting new technologies are always doubts about their cost-utility in scenarios with scarce health resources. This study aimed to evaluate the cost-utility of sputum eosinophil counts to guide management in children with asthma, from a societal perspective.

METHODS

A Markov simulation with three mutually exclusive nonabsorbent states was used. The intervention evaluated was adjustment of asthma therapy based on sputum eosinophils to adjusting therapy based on clinical symptoms with or without spirometry/peak flow in children between 4 and 18 years of age (EO). The group comparison was adjusting therapy based on clinical symptoms with or without spirometry/peak flow (SC). The analysis was carried out from a societal perspective. The analytic horizon was 12 months.

RESULTS

The model showed that EO was associated with lower cost than SC (US $1375 vs US $1454 average annual cost per patient), and higher QALYs (0.95 vs 0.92 average per patient); showing dominance. The probability that EO provides a more cost-effective use of resources compared with standard therapy exceeds 99% for all willingness to pay thresholds.

CONCLUSION

EO was cost-effective for infants with asthma to guide asthma management in Children. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines and should be replicated to validate their results in other middle-income countries.