Cost-Effectiveness of Zonisamide Versus Levetiracetam in Newly Diagnosed Focal Onset Epilepsy in Serbia

Which is the most cost-effective antiseizure medication for initial monotherapy for focal epilepsy?

OBJECTIVE

An increasing number of antiseizure medications (ASMs) are approved for monotherapy for focal epilepsy, but direct comparisons of the lifetime cost-effectiveness of all existing treatment strategies are lacking. This study aims to compare the cost-effectiveness of new ASMs and traditional ASMs as first-line monotherapy for newly diagnosed focal epilepsy.

METHOD

We used a Markov model to evaluate the lifetime cost-effectiveness of 10 ASMs in the treatment of focal epilepsy, with lacosamide (LCM) as a control, from the perspective of society in the United States. Effectiveness, cost data, and health state utilities were obtained from published literature. The cycle of the model is 6 months. Willingness to pay was defined as $150 000 per quality-adjusted life year (QALY). One-way and probabilistic sensitivity analyses were conducted to evaluate parameter uncertainty, and several scenario analyses were also conducted.

RESULTS

The base case analysis showed that carbamazepine (CBZ) was the least costly ASM and more effective than valproic acid (VPA), levetiracetam (LEV), gabapentin (GBP), topiramate (TPM), and lamotrigine (LTG) from an American social perspective. In contrast, oxcarbazepine (OXC), phenytoin (PHT), phenobarbitone (PHB), LCM, and zonisamide (ZNS) were more effective than CBZ, with incremental cost-effectiveness ratios of $334 703.50, $325 610.99, $3 037 148.62, $1 178 954.91, and $108 153 360.85/QALY, respectively. The traditional ASMs were ranked as CBZ, PHT, VPA, and PHB; the new ASMs were ranked as OXC, LEV, LCM, LTG, TPM, GBP, and ZNS. When generic drugs are used, PHT, OXC, and CBZ remain the three most cost-effective options.

SIGNIFICANCE

In terms of cost-effectiveness, CBZ monotherapy is the best option for newly diagnosed focal epilepsy, followed by OXC, PHT, VPA, LEV, PHB, LCM, LTG, TPM, GBP, and ZNS. Most traditional ASMs are more cost-effective than new ASMs; OXC is an exception.

Monetary value of health-a practical decision-making framework combining equity considerations and WTP

OBJECTIVE

We estimate the first monetary value of a health gain in Croatia to inform the debate about the appropriate "demand-side" cost-effectiveness thresholds in Croatia but also Central and Eastern Europe, where such debates are still uncommon. We test the empirical support for two equity considerations: age and severity operationalized as proportional shortfall (PS), and propose a pragmatic framework for combining equity considerations with the monetary value of health into a single threshold.

METHODS

We used the contingent valuation method to elicit the willingness to pay per Quality-Adjusted Life Year (QALY) in Croatia, using a representative sample of the population (N = 1,500, online survey). 29 EQ-5D health states were valued using payment scales and open-ended question as payment vehicles. To test the hypotheses, we used both parametric tests and non-parametric tests. Multilinear regression was employed to test the theoretical validity of the results.

RESULTS

The monetary value of a health gain in Croatia is equivalent to 1.15 of GDP per capita (equaling €17,000). Age of patients seems to be an important equity-related characteristic. The WTP per QALY in the age-neutral risk group (€11,900) was nearly equivalent to the WTP per QALY in the adult (neutral) risk group (€11,700) but lower by 16% compared to the WTP per QALY estimated in children (€14,200; p = 0.00). WTP estimates are theoretically valid and to, a small degree, scale sensitive. There is a positive association between the level of proportional shortfall and willingness to pay. To increase the usefulness of our results for the policy-makers, we combine the elicited preferences into a single decision-making framework and construct several cost-effectiveness thresholds based on willingness to pay and equity-related preferences. Based on empirical results, cost-effectiveness thresholds could range up to €20,308 for the most severe health conditions in children or could be lowered to €16,777 for less severe health conditions.

DISCUSSION

In Central and Eastern Europe, in spite of a growing understanding of the importance of further developing value-based assessment frameworks there has been very little empirical research to guide, inform and promote this development. Countries in this region use mainly GDP-based thresholds without empirical evidence to support such important decisions. This may lead to thresholds that are too high, with detrimental consequence for the pricing and reimbursement systems.

Cost-effectiveness of miglustat versus symptomatic therapy of Niemann-Pick disease type C

BACKGROUND

Niemann-Pick disease type C (NP-C) is a progressive neurodegenerative disorder with early infantile (< 2 years), late infantile (2-6 years), juvenile (7-15 years) and adolescent (> 15 years) onset. The mainstay of therapy for NP-C patients with neurological symptoms is miglustat, a drug that may modify the course of the disease.

AIM

Our aim was to evaluate the cost-effectiveness of miglustat in comparison to symptomatic therapy in patients with NP-C in the socio-economic settings of the Republic of Serbia, an upper-middle-income European economy.

METHOD

The perspective of the Serbian Republic Health Insurance Fund was chosen for this study, and the time horizon was eighty years. The main outcomes of the study were quality-adjusted life years gained with miglustat and comparator, and direct costs of treatment. The study was conducted through the generation and simulation of the Discrete-Event Simulation model. The model results were obtained after Monte Carlo microsimulation of a sample with 1000 virtual patients.

RESULTS

Treatment with miglustat was not cost-effective when compared with symptomatic therapy and was associated with negative values of net monetary benefit regardless of the onset of neurological manifestations (- 110,447,627.00 ± 701,614.00 RSD, - 343,871,695.00 ± 2,577,441.00 RSD, - 1,397,908,502.00 ± 23,084,235.00 RSD and - 2,953,680,879.00 ± 33,297,412.00 RSD) for early infantile, late infantile, juvenile and adolescent cohorts, respectively).

CONCLUSION

When traditional pharmacoeconomic evaluation is employed, miglustat is not a cost-effective option in comparison to symptomatic therapy for the treatment of NP-C. However, given the proven efficacy of miglustat, there is a need to find ways to make this drug available to all patients with NP-C.