1
|
Tamayo C, Huertas J, Sanmartin D, Ordóñez A, Ávila D, Mendoza F, Orozco E. Cost-Effectiveness of Tacrolimus Compared With Cyclosporine for Immunosuppression Therapy in Patients Who Underwent Heart Transplant in Colombia. Value Health Reg Issues 2023; 38:61-68. [PMID: 37573854 DOI: 10.1016/j.vhri.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/19/2023] [Accepted: 06/29/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVES To evaluate the cost-effectiveness of pharmacological treatment in maintenance therapy for adult heart transplant recipients from the Colombian health system perspective. METHODS We constructed a decision tree model with a 1-year time horizon. A review of the clinical literature was performed to extract probabilities of health events and acute rejections avoided were used as the health outcome. Costs were calculated from the base-case approximation and were obtained from administrative databases in Colombia (Sistema de Información de Precios de Medicamentos 2020 and Suficiencia 2012-2019), and the prices were adjusted to US dollar 2021. RESULTS Two evaluation results were presented. The first evaluates the tacrolimus + azathioprine + corticosteroid (TAC) scheme compared with cyclosporine + azathioprine + corticosteroid (CAC), in which the incremental cost-effectiveness ratio indicates that 1 additional rejection avoided has a cost of US dollar $5461.09 which, compared with the cost-effectiveness threshold in the base case, indicates that the TAC scheme is not a cost-effective (CE) strategy with respect to the CAC scheme. The second result shows the comparison of tacrolimus + mycophenolate mofetil + corticosteroid (TMC) with cyclosporine + mycophenolate mofetil + corticosteroid (CMC) in which TMC was found to be a dominant alternative to CMC. CONCLUSIONS The tacrolimus-based immunosuppression scheme is not CE in its TAC scheme, versus CAC, and is dominant in its TMC scheme, versus CMC, sensitivity analyses show that tacrolimus could become a CE alternative in any scheme used against higher cost-effectiveness threshold.
Collapse
Affiliation(s)
- Camilo Tamayo
- Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá DC, Colombia; Universidad Nacional de Colombia, Bogotá DC, Colombia.
| | - Juliana Huertas
- Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá DC, Colombia
| | - Daysi Sanmartin
- Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá DC, Colombia; Universidad de Antioquia, Medellín, Colombia
| | - Angélica Ordóñez
- Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá DC, Colombia
| | - Diego Ávila
- Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá DC, Colombia; Universidad Nacional de Colombia, Bogotá DC, Colombia
| | | | - Esteban Orozco
- Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá DC, Colombia; Universidad de Antioquia, Medellín, Colombia
| |
Collapse
|
2
|
Helmschrott M, Beckendorf J, Akyol C, Ruhparwar A, Schmack B, Erbel C, Gleissner CA, Akhavanpoor M, Ehlermann P, Bruckner T, Katus HA, Doesch AO. Superior rejection profile during the first 24 months after heart transplantation under tacrolimus as baseline immunosuppressive regimen. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:1307-14. [PMID: 25246772 PMCID: PMC4166906 DOI: 10.2147/dddt.s68542] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background The use of tacrolimus (TAC) in patients after heart transplantation (HTX) has increased over the last few years. Aim In this retrospective study, we evaluated the effects of a TAC (conventional and extended-release TAC)-based immunosuppressive therapy regarding rejection profile in comparison to a cyclosporine A (CSA)-based regimen in patients after HTX. Methods The data of 233 patients who underwent HTX at the Heidelberg Heart Transplantation Center from May 1998 until November 2010 were retrospectively analyzed. Primary immunosuppressive therapy was changed from a CSA (n=114) to a TAC (n=119)-based regimen in February 2006 according to center routine. Follow-up period was 2 years post-HTX. Primary endpoint was time to first biopsy-proven rejection requiring therapy. In all patients, routine follow-up at the Heidelberg Heart Transplantation Center was mandatory. Results Multivariate risk factor analysis regarding time to first rejection episode showed no statistically significant differences regarding recipient age, donor age, recipient sex, donor sex, sex mismatch, ischemic time, and diagnosis leading to HTX between the two groups (all P= not statistically significant). Time to first biopsy-proven rejection was significantly longer in the TAC group (intention-to-treat analysis, n=233, log-rank test P<0.0001; per-protocol analysis, n=150, log-rank test P=0.0003). In patients who underwent a change of primary immunosuppression (n=49), a significantly longer time to first biopsy-proven rejection was also found in the primary TAC subgroup (log-rank test P=0.0297). Further subgroup analysis in the TAC subgroups showed no statistically significant differences in time to biopsy-proven rejection under extended-release TAC compared to conventional TAC (intention-to-treat analysis, log-rank test P=0.1736). Conclusion Our study demonstrated that a TAC-based primary immunosuppressive therapy is superior to a CSA-based immunosuppressive regimen in patients after HTX regarding time to first biopsy-proven rejection.
Collapse
Affiliation(s)
- Matthias Helmschrott
- Department of Cardiology, Angiology, Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Jan Beckendorf
- Department of Cardiology, Angiology, Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Ceylan Akyol
- Department of Cardiology, Angiology, Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Christian Erbel
- Department of Cardiology, Angiology, Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Christian A Gleissner
- Department of Cardiology, Angiology, Pneumology, University of Heidelberg, Heidelberg, Germany
| | | | - Philipp Ehlermann
- Department of Cardiology, Angiology, Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Tom Bruckner
- Institute for Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, Angiology, Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Andreas O Doesch
- Department of Cardiology, Angiology, Pneumology, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
3
|
Ten-Year Results of a Randomized Trial Comparing Tacrolimus Versus Cyclosporine A in Combination With Mycophenolate Mofetil After Heart Transplantation. Transplantation 2013; 95:629-34. [DOI: 10.1097/tp.0b013e318277e378] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
4
|
Penninga L, Møller CH, Gustafsson F, Steinbrüchel DA, Gluud C. Tacrolimus versus cyclosporine as primary immunosuppression after heart transplantation: systematic review with meta-analyses and trial sequential analyses of randomised trials. Eur J Clin Pharmacol 2010; 66:1177-87. [PMID: 20882273 DOI: 10.1007/s00228-010-0902-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Accepted: 09/05/2010] [Indexed: 01/08/2023]
Abstract
PURPOSE We conducted a systematic review of randomized trials to compare the benefits and harms of tacrolimus versus cyclosporine as primary immunosuppression after heart transplantation. METHODS AND RESULTS We searched electronic databases and bibliographies up to April 2010. Our review followed the Cochrane and PRISMA guidelines. The meta-analysis included 10 randomized trials with 952 patients. Tacrolimus was significantly superior to cyclosporine (both formula-combined) with regard to hypertension (relative risk [RR] 0.8; 95% confidence interval [CI] 0.69-0.93, p = 0.003), hyperlipidaemia (RR 0.57; 95% CI 0.44-0.74, p < 0.0001), hirsutism (RR 0.17 95% CI 0.04-0.62, p = 0.008), and gingival hyperplasia (RR 0.07 95% CI 0.01-0.37, p = 0.002). No significant differences between the two calcineurin inhibitors were found with regard to acute rejections causing haemodynamic instability, diabetes, renal dysfunction, infection, malignancy, or neurotoxicity. Tacrolimus was significantly superior to microemulsion cyclosporine with regard to mortality (RR 0.64; 95% CI 0.42-0.96, p = 0.03), acute severe biopsy-proven rejection (RR 0.71; 95% CI 0.56-0.90, p = 0.004), hyperlipidaemia (RR 0.57; 95% CI 0.41-0.79, p = 0.0009), hirsutism (RR 0.17 95% CI 0.04-0.62, p = 0.008), and gingival hyperplasia (RR 0.07; 95% CI 0.01-0.37, p = 0.002). Tacrolimus was significantly superior to oil-based cyclosporine with regard to hypertension (RR 0.66; 95% CI 0.54-0.80, p < 0.0001), and hyperlipidaemia (RR 0.57; 95% CI 0.38-0.87, p = 0.009). CONCLUSION Tacrolimus seems to be superior to cyclosporine in heart transplant patients with regard to hypertension, hyperlipidaemia, gingival hyperplasia and hirsutism. In addition, tacrolimus seems to be superior to microemulsion cyclosporine in heart transplant patients with regard to a number of outcomes, including death. More trials with a low risk of bias are needed to determine if the results of the present meta-analysis can be confirmed.
Collapse
Affiliation(s)
- Luit Penninga
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Cochrane Hepato-biliary Group, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | | | | | | | | |
Collapse
|
5
|
Sánchez-Lázaro IJ, Almenar L, Martínez-Dolz L, Buendía-Fuentes F, Agüero J, Navarro-Manchón J, Vicente JL, Salvador A. A prospective randomized study comparing cyclosporine versus tacrolimus combined with daclizumab, mycophenolate mofetil, and steroids in heart transplantation. Clin Transplant 2010; 25:606-13. [PMID: 20682020 DOI: 10.1111/j.1399-0012.2010.01309.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ignacio J Sánchez-Lázaro
- Heart Failure and Transplantation Unit, Cardiology Department, Hospital Universitario La Fe, Valencia, Spain.
| | | | | | | | | | | | | | | |
Collapse
|
6
|
Ye F, Ying-Bin X, Yu-Guo W, Hetzer R. Tacrolimus versus cyclosporine microemulsion for heart transplant recipients: a meta-analysis. J Heart Lung Transplant 2008; 28:58-66. [PMID: 19134532 DOI: 10.1016/j.healun.2008.10.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 10/09/2008] [Accepted: 10/14/2008] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tacrolimus and cyclosporine microemulsion are the 2 major immunosuppressants for heart transplantation. Several studies have compared these 2 drugs, but the outcomes were not consistent. This meta-analysis of randomized controlled trials compared the beneficial and harmful effects of tacrolimus and microemulsion cyclosporine for heart transplant recipients. METHODS Electronic databases and manual bibliography searches were conducted. A meta-analysis was performed of all randomized controlled trials comparing tacrolimus with cyclosporine microemulsion as primary immunosuppression for heart transplant recipients. Data for mortality, acute rejection, withdrawals, and adverse events were extracted. The combined results of the data of the randomized controlled trials were summarized as relative risk with 95% confidence intervals. RESULTS The study assessed 7 randomized controlled trials including 885 patients. There was no difference in mortality at 1 year between recipients treated with tacrolimus and cyclosporine microemulsion. Tacrolimus-treated patients had less acute rejection risk at 6 months and 1 year. Fewer patients stopped tacrolimus than cyclosporine microemulsion. The rate of new-onset diabetes mellitus requiring insulin treatment was higher with tacrolimus. More post-transplantation hypertension occurred with cyclosporine microemulsion. The groups had comparable incidences of malignancy and renal failure needing dialysis. CONCLUSIONS The use of tacrolimus as primary immunosuppressant for heart transplant recipients results in comparable survival and a significant reduction in acute rejection compared with cyclosporine microemulsion.
Collapse
Affiliation(s)
- Fan Ye
- Department of Cardiothoracic and Vascular Surgery, Chongqing Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | | | | | | |
Collapse
|
7
|
Abstract
Cardiac allograft vasculopathy (CAV) remains a life-threatening complication after heart transplantation (HT). Recipients with severe intimal thickening are 10-fold more likely to suffer cardiac events than those without severe hyperplasia. From July 1987 to July 2007, we performed 323 HTs with 5-year actuarial freedom from CAV of 69%, similar to the data reported by the International Society for Heart and Lung Transplantation, namely, 68% at 5 years. Therefore, CAV is not uncommon in Asia. The pathogenesis of CAV is initial endothelial injury followed by intimal hyperplasia and proliferation of vascular smooth muscle cells. It may be caused by both immunological events (involving T or B cells in response to donor major histocompatibility antigens, or natural killer [NK] cell-triggered recruitment of T cells not responsive to donor alloantigen) and nonimmunologic factors, such as older age, ischemia-reperfusion injury, viral infection (particularly cytomegalovirus [CMV] infection), immunosuppressive drugs, and classic risk factors, such as hyperlipidemia, insulin resistance, and hypertension. The therapy for CAV has been disappointing, despite prescriptions of statin lipid-lowering agents, calcium-channel blockers, angiotensin-converting enzyme inhibitors, and antiproliferative drugs. Patients with CAV are often not amenable to successful revascularization (medical or surgical) because of the diffuse obliterative process. Prophylaxis of CAV starts with modification of risk factors: hypertension, hyperlipemia, hyperglycemia, obesity, and smoking, as well as promotion of exercise programs. The HMG-CoA reductase inhibitors and antiproliferative drugs may slow the progression of CAV by various immunologic and nonimmunologic effects. Prevention of CMV infection reduces CAV. Mycophenolate mofetil and signal transduction inhibitors, such as everolimus, reduce intimal thickening and CAV.
Collapse
Affiliation(s)
- S-S Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
8
|
Wang SS, Chou NK, Chi NH, Wu IH, Chen YS, Yu HY, Huang SC, Wang CH, Ko WJ, Tsao CI, Sun CD. Heart transplantation under cyclosporine or tacrolimus combined with mycophenolate mofetil or everolimus. Transplant Proc 2008; 40:2607-8. [PMID: 18929814 DOI: 10.1016/j.transproceed.2008.08.072] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE In this study, we examined whether cyclosporine was effective when combined with everolimus in clinical heart transplantation (HT). PATIENTS AND METHODS From August 2004 to July 2007, 108 adult patients underwent primary HT. The main exclusion criteria were: donors > 60 years; cold ischemia times > 6 hours; recipients of multiorgan transplantation or a previous transplantation; and panel-reactive antibodies > or = 25%. The cyclosporine plus everolimus regimen (group CE, n = 32) was suggested first; upon refusal or if the recipient or donor was positive for hepatitis B surface antigen or PCR + hepatitis C infection, then patient was randomly assigned to success cyclosporine plus mycophenolate mofetil (MMF; group CM, n = 24) or tacrolimus plus MMF (group TM, n = 25). All patients underwent similar operative procedures and postoperative care with protocol endomyocardial biopsies. RESULTS No 30-day mortality was noted in any group. The efficacy failure rates were 3%, 25%, and 16% in groups CE, CM, and TM, respectively (P = .04 between groups CE and CM). The 1-year survivals were 96.7% +/- 18.1%, 89.7% +/- 29.8%, and 81.0% +/- 35.5% for groups CE, CM, and TM, respectively (P = .04 between groups CE and TM). The 3-year survival rates were 91.9% +/- 28.3%, 79.8% +/- 46.0%, and 81.0% +/- 35.5% in groups CE, CM, and TM, respectively. CONCLUSIONS The 3 immunosuppressive regimens offered good efficacy after HT. The cyclosporine plus everolimus regimen showed a significantly better result with less efficacy failure (compared with cyclosporine plus MMF: 3% vs 25%) and better 1-year survival compared with tacrolimus plus MMF: 96.7% vs 81.0%.
Collapse
Affiliation(s)
- S S Wang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Wang CH, Chou NK, Ko WJ, Chi NH, Tsao CI, Wang SS. The impact on biochemical profiles and allograft function for patients converted from cyclosporine to tacrolimus after clinical heart transplantation. Transplant Proc 2008; 40:2600-2. [PMID: 18929812 DOI: 10.1016/j.transproceed.2008.08.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Tacrolimus, a potent calcineurin inhibitor, is a widely used immunosuppressant. This study sought to determine whether conversion from cyclosporine to tacrolimus afforded benefits on biochemical profiles and graft function among Chinese heart transplantation recipients. METHODS Forty-nine patients (44 men and 5 women) among 252 heart transplantations performed from 1995 to 2005 were converted from cyclosporine to tacrolimus due to rejection (69%) or to cyclosporine intolerance (31%). The median age of these recipients at transplantation was 46.4 years (range, 5 months to 68 years). Their median body weight was 60 kg (range, 4-84 kg). The allograft median ischemic time was 145 minutes (range, 52-300 minutes). We compared the biochemical markers, rejection episodes and allograft function. RESULTS The mean duration from heart transplantation to conversion was 419 days. After conversion, the serum bilirubin and alanine transaminase levels were significantly improved at 1 year. The lipid profiles, including triglycerides, total cholesterol, and low-density lipoprotein were nonsignificantly changed. The rejection episodes significantly decreased from 1.53 to 0.15 per patient per year (P < .001). The left ventricular ejection fraction significantly improved from 54.3 +/- 17.9% to 63.2 +/- 10.9% (P < .01). The right atrial pressure significantly decreased from 9.1 +/- 5.8 mmHg to 6.3 +/- 4.3 mm Hg (P < .01). The pulmonary capillary wedge pressure significantly decreased from 15.3 +/- 9.5 mm Hg to 10.8 +/- 5.3 mm Hg (P = .04). CONCLUSION In heart transplantation, conversion to tacrolimus owing to rejection or cyclosporine intolerance showed better liver profiles with fewer rejection episodes and improved graft function.
Collapse
Affiliation(s)
- C H Wang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | | | | | | | | | | |
Collapse
|
10
|
Karasulu HY. Microemulsions as novel drug carriers: the formation, stability, applications and toxicity. Expert Opin Drug Deliv 2007; 5:119-35. [DOI: 10.1517/17425247.5.1.119] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
11
|
Wang SS, Chou NK, Ko WJ, Chi NH, Hung SC, Hsu RB, Yu HY, Chen YS, Chu SH, Tsao CI, Shun CT. Effect of Plasmapheresis for Acute Humoral Rejection After Heart Transplantation. Transplant Proc 2006; 38:3692-4. [PMID: 17175369 DOI: 10.1016/j.transproceed.2006.10.060] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The objective of this study was to report our experience of treating acute humoral rejection with plasmapheresis in heart transplant (HT) recipients. PATIENTS AND METHODS From May 1996 to December 2005, 238 HTs were performed using therapy with cyclosporine or tacrolimus, azathioprine or mycophenolate mofetil, and prednisolone as well as induction treatment with rabbit anti-human thymocyte globulin. Endomyocardial biopsy for rejection surveillance was performed weekly for the first month, monthly for 3 months, yearly after the first year, and whenever rejection was suspected. Immunofluorescence studies with IgG, IgM, C3, C4, C1q, and HLA-DR were performed routinely on the first month biopsy. After a 2-year trial, immunofluorescence studies were not performed routinely, because no significant findings were observed; thus they were performed only when clinical deterioration, unstable hemodynamic status, or suspicion of rejection occurred on routine echocardiographic examinations. Plasmapheresis with fresh frozen plasma exchanging twice the blood volume of the patients was performed for 5 days. Rescue immunosuppression with methylprednisolone (1 g/d) was delivered for 3 days and the immunosuppressants changed, but no intravenous immunoglobulin was prescribed. RESULTS Twelve patients suffered biopsy-proven acute humoral rejection at 3 days to 32 months after HT (mean, 9.4 months). Immunofluorescence studies showed positive HLA-DR in 7 patients; IgG in 4 patients; IgM in 1 patient; C3 in 4 patients; C4 in 1 patient; and C1q in 1 patient. One patient who was 3 months after HT showed only C1q positive but was treated with extracorporeal membrane oxygenation and intra-aortic balloon pumping support and died 1-month after plasmapheresis. Another patient who deteriorated on the 3rd postoperative day and died 3 days after plasmapheresis was considered to have vascular rejection by interstitial edema, vacuolated endothelial cells and no pathognomonic clinical features, although there was no positive immunofluorescence result. All other subjects were discharged from the hospital, although 3 required mechanical support during plasmapheresis. Hypotension with hypocalcemia was frequently noted during plasmapheresis. The 1-year survival rate was 75% +/- 11%, and 5-year survival rate, 51% +/- 15%. CONCLUSION Plasmapheresis with concurrent rescue immunosuppression was an effective treatment for acute humoral rejection in HT even with unstable hemodynamics.
Collapse
Affiliation(s)
- S-S Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2005. [DOI: 10.1002/pds.1028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|