A cost-effectiveness analysis of lisdexamfetamine dimesylate in the treatment of adults with attention-deficit/hyperactivity disorder in the UK

Cost-effectiveness and budget impact analysis of lisdexamfetamine versus methylphenidate for patients under 18 with attention-deficit/hyperactivity disorder in Iran

BACKGROUND

Lisdexamfetamine (LDX) and Methylphenidate (MPH) are stimulant agents that have been shown to provide significant benefits in the management of attention-deficit/hyperactivity disorder (ADHD) in patients.

AIM

This study aimed to assess the cost-effectiveness and the budget impact of LDX compared to MPH as the first-line treatment for ADHD.

METHODS

A one-year cost-effectiveness analysis (CEA) was conducted to compare the effects of LDX and MPH in reducing disease symptoms and patient costs and improving quality of life (QoL) from a social perspective. Clinical data were obtained using the EQ-5D questionnaire. In contrast, economic data were sourced from the official website of the Iranian Food and Drug Association (FDA), the national book of tariffs, and specific questionnaires designed to evaluate patients' direct and indirect costs. 197 patients were included in the study, including individuals who sought psychiatric evaluation at a hospital in Mashhad and those who obtained ADHD medications from governmental pharmacies. The cost-effectiveness of the study medicine was assessed using the decision tree method, and the results were presented as the Incremental Cost-Effectiveness Ratio (ICER). Deterministic Sensitivity Analysis (DSA) and Probabilistic Sensitivity Analysis (PSA) were performed to assess the robustness of the findings. Additionally, a Budget Impact Analysis (BIA) was conducted over five years, considering three different scenarios, to evaluate the financial implications of incorporating LDX into the national pharmaceutical system.

RESULTS

The ICER for LDX therapy compared to MPH was estimated at USD 264.28 (with an incremental cost of USD 54.9, incremental effectiveness of 0.208, and Quality-Adjusted Life Years (QALYs) gained of 0.765). The PSA indicated a 0.994% probability of LDX being cost-effective, considering a threshold of USD 2450 per QALY. Furthermore, the DSA revealed that the acquisition cost of LDX influenced the model's sensitivity. The BIA demonstrated that incorporating LDX into Iran's healthcare system would result in a financial burden of approximately $368,566 in the first year, representing an additional cost of $11,154 compared to the non-availability of this medicine and the use of previous medications. It is projected that by 2027, the financial burden of treating ADHD with LDX will reach approximately USD 443,879 over five years, amounting to an increase of $71,154 compared to the absence of this medicine.

CONCLUSION

From a social perspective, the inclusion of LDX in the treatment regimen for ADHD is associated with higher costs and an increased financial burden. However, based on our analysis, LDX appears to be a cost-effective choice for managing ADHD in Iran when compared to MPH.

Adverse Drug Reaction Reporting and Prescribing Trends of Drugs for Attention Deficit Hyperactivity Disorder in Primary Care England, 2010-2019

OBJECTIVE

We investigated the prescription trends and adverse drug reactions (ADRs) of ADHD drugs in primary care, England between 2010 and 2019.

METHODS

The Prescription Cost Analysis database presenting the primary care prescriptions data and the Interactive Drug Analysis Profiles presenting all suspected ADRs reported for each drug were screened. The data were analyzed using linear regression analysis to examine the annual average change per year.

RESULTS

The prescription items dispensed for ADHD showed an average 11.07% (95% CI 10.54-11.60, p = .001) increase per year and there was a mean 11.54% (95% CI 11.03-12.06, p = .001) increase per year in the costs. The overall reporting of serious and fatal ADR was reduced by 1.79% per year for ADHD drugs. Guanfacine showed a 40% mean increase per year.

CONCLUSION

The increasing use of ADHD drugs within primary care in England could be a result of multiple factors such as growing ADHD prevalence.

Cost-Effectiveness and Cost Utility of Treatment of Attention-Deficit/Hyperactivity Disorder: A Systematic Review

Objectives: This systematic review provides an overview of full economic evaluations of attention-deficit/hyperactivity disorder (ADHD) treatments, evaluates their outcomes, and highlights gaps in the literature. Data Sources: Electronic databases were searched for full economic evaluations of ADHD treatments for children, adolescents, or adults published in English or Dutch. Results: Twenty-nine studies met the inclusion criteria. Almost all studies that compared medication or psychosocial treatment to no treatment, placebo, or care as usual indicated that medication and psychosocial treatment were cost-effective compared to the control group. Stimulant treatment appeared to be cost-effective for the treatment of ADHD in children and adolescents. Only few studies focus on treatments in adults and psychosocial treatments and the number of studies with long time horizons and without industry funding is limited. Conclusions: Despite the rising interest in cost-effectiveness, this systematic review shows that more cost-effectiveness research of higher quality is warranted to aid in the optimal use of available treatments and resources for individuals with ADHD. Specifically, more studies should focus on treatments in adults and psychosocial treatments, and more studies with long time horizons and without industry funding are warranted. Nevertheless, we can conclude that treating ADHD is generally cost-effective compared to no treatment. PROSPERO: CRD42017060074. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=60074.

Welfare consequences for people diagnosed with attention deficit hyperactivity disorder (ADHD): A matched nationwide study in Denmark

There is insufficient data regarding the excess direct and indirect costs associated with attention deficit hyperactivity disorder (ADHD). Using the Danish National Patient Registry (2002-2016), we identified 83,613 people of any age with a diagnosis of ADHD or who were using central-acting medication against ADHD (primarily methylphenidate, with at least two prescriptions) and matched them to 334,446 control individuals. Additionally, 18,959 partners of patients aged ≥18 years with ADHD were identified, and compared with 74,032 control partners. Direct costs were based on data from the Danish Ministry of Health. Information about the use and costs of drugs were obtained from the Danish Medicines Agency. The frequencies of visits and hospitalizations, and costs of general practice were derived from data from the National Health Security. Indirect costs were obtained from Coherent Social Statistics. The average annual health care costs for people with ADHD and their partners were, respectively, €2636 and €477 higher than those of the matched controls. A greater percentage of people with ADHD and their partners compared with respective control subjects received social services (sick pay or disability pension). Those with ADHD had a lower income from employment than did controls for equivalent periods up to five years before the first diagnosis of ADHD. The additional direct and indirect annual costs (for those aged ≥18 years) including transfers of ADHD compared with controls were €23,072 for people with ADHD and €7,997 for their partners. ADHD has substantial socioeconomic consequences for individual patients, their partners and society.

Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis

BACKGROUND

The benefits and safety of medications for attention-deficit hyperactivity disorder (ADHD) remain controversial, and guidelines are inconsistent on which medications are preferred across different age groups. We aimed to estimate the comparative efficacy and tolerability of oral medications for ADHD in children, adolescents, and adults.

METHODS

We did a literature search for published and unpublished double-blind randomised controlled trials comparing amphetamines (including lisdexamfetamine), atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, and modafinil with each other or placebo. We systematically contacted study authors and drug manufacturers for additional information. Primary outcomes were efficacy (change in severity of ADHD core symptoms based on teachers' and clinicians' ratings) and tolerability (proportion of patients who dropped out of studies because of side-effects) at timepoints closest to 12 weeks, 26 weeks, and 52 weeks. We estimated summary odds ratios (ORs) and standardised mean differences (SMDs) using pairwise and network meta-analysis with random effects. We assessed the risk of bias of individual studies with the Cochrane risk of bias tool and confidence of estimates with the Grading of Recommendations Assessment, Development, and Evaluation approach for network meta-analyses. This study is registered with PROSPERO, number CRD42014008976.

FINDINGS

133 double-blind randomised controlled trials (81 in children and adolescents, 51 in adults, and one in both) were included. The analysis of efficacy closest to 12 weeks was based on 10 068 children and adolescents and 8131 adults; the analysis of tolerability was based on 11 018 children and adolescents and 5362 adults. The confidence of estimates varied from high or moderate (for some comparisons) to low or very low (for most indirect comparisons). For ADHD core symptoms rated by clinicians in children and adolescents closest to 12 weeks, all included drugs were superior to placebo (eg, SMD -1·02, 95% CI -1·19 to -0·85 for amphetamines, -0·78, -0·93 to -0·62 for methylphenidate, -0·56, -0·66 to -0·45 for atomoxetine). By contrast, for available comparisons based on teachers' ratings, only methylphenidate (SMD -0·82, 95% CI -1·16 to -0·48) and modafinil (-0·76, -1·15 to -0·37) were more efficacious than placebo. In adults (clinicians' ratings), amphetamines (SMD -0·79, 95% CI -0·99 to -0·58), methylphenidate (-0·49, -0·64 to -0·35), bupropion (-0·46, -0·85 to -0·07), and atomoxetine (-0·45, -0·58 to -0·32), but not modafinil (0·16, -0·28 to 0·59), were better than placebo. With respect to tolerability, amphetamines were inferior to placebo in both children and adolescents (odds ratio [OR] 2·30, 95% CI 1·36-3·89) and adults (3·26, 1·54-6·92); guanfacine was inferior to placebo in children and adolescents only (2·64, 1·20-5·81); and atomoxetine (2·33, 1·28-4·25), methylphenidate (2·39, 1·40-4·08), and modafinil (4·01, 1·42-11·33) were less well tolerated than placebo in adults only. In head-to-head comparisons, only differences in efficacy (clinicians' ratings) were found, favouring amphetamines over modafinil, atomoxetine, and methylphenidate in both children and adolescents (SMDs -0·46 to -0·24) and adults (-0·94 to -0·29). We did not find sufficient data for the 26-week and 52-week timepoints.

INTERPRETATION

Our findings represent the most comprehensive available evidence base to inform patients, families, clinicians, guideline developers, and policymakers on the choice of ADHD medications across age groups. Taking into account both efficacy and safety, evidence from this meta-analysis supports methylphenidate in children and adolescents, and amphetamines in adults, as preferred first-choice medications for the short-term treatment of ADHD. New research should be funded urgently to assess long-term effects of these drugs.

FUNDING

Stichting Eunethydis (European Network for Hyperkinetic Disorders), and the UK National Institute for Health Research Oxford Health Biomedical Research Centre.