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Zhang X, Ge Z, Chen B, Liu R, Gao C. Efficacy and safety evaluation of fludarabine-based chemotherapy regimen for patients with non-Hodgkin lymphoma: A meta-analysis. Medicine (Baltimore) 2017; 96:e7781. [PMID: 28816963 PMCID: PMC5571700 DOI: 10.1097/md.0000000000007781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This meta-analysis was performed to evaluate the efficacy and safety of fludarabine (F)-based regimen for the treatment of non-Hodgkin lymphoma (NHL) compared with other regimens with no F contained.PubMed, Embase, Cochrane Library, Wanfang, VIP, and CNKI databases were searched to identify eligible literatures. R software version 3.12 was used for statistical analysis. Odds ratio (OR) with 95% confidence interval (CI) were utilized to express the complete response, overall response and adverse events outcomes. Egger test was carried out to examine the publication bias and sensitivity analysis was performed to evaluate the stability of our results.Twelve eligible literatures consisting of 1587 patients were included in this study. Greater complete response (OR = 1.66, 95% CI: 0.98-2.80) and overall response (OR = 1.38, 95% CI: 0.85-2.24) were found for patients who received F-based regimen than those received other regimens, although the results were not statistically significant. In addition, F-based regimen was associated with significantly lower risk of adverse events compared with other regimens (OR = 0.46, 95% CI: 0.28-0.74). Results of subgroup analysis showed that significantly lower incidence was presented only for constipation among the 7 specific adverse events (OR = 0.03, 95% CI: 0.01-0.14).F-based chemotherapy regimen was an effective and well-tolerated treatment for patients with NHL.
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Lien K, Cheung MC, Chan KK. Adjusting for Drug Wastage in Economic Evaluations of New Therapies for Hematologic Malignancies: A Systematic Review. J Oncol Pract 2016; 12:e369-79. [DOI: 10.1200/jop.2015.005876] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Purpose: As costs of cancer care rise, there has been a shift to focus on value. Drug wastage affects costs to patients and health care systems without adding value. Historically, cost-effectiveness analyses have used models that assume no drug wastage; however, this may not reflect real-world practices. We sought to identify the frequency of drug wastage modeling in economic evaluations of modern parenteral therapies for hematologic malignancies. Methods: We conducted a systematic literature review of economic evaluations of new US Food and Drug Administration–approved parenteral chemotherapies with indications for the treatment of hematologic malignancies. The primary outcome of interest was the proportion of studies that modeled drug wastage in base-case analyses. If wastage was considered in primary analyses, we reported the impact of wastage on incremental cost-effectiveness ratios (ICERs) and drug acquisition costs. Results: Wastage was considered in base-case analyses in less than one third of all publications reviewed (12 of 38; 32%). Of these, two studies went on to complete sensitivity analyses and reported significant changes in the calculated ICER as a result. In one study, the ICER increased by 32%, and in the second, accounting for wastage changed a positive ICER to a dominant result. Conclusion: Potential costs associated with drug wastage are considered in only one third of modern cost-effectiveness models. The impact of wastage on calculated ICERs and drug acquisition costs is potentially substantial. The modeling of wastage in base-case and sensitivity analyses is recommended for future economic evaluations of new intravenous therapies for hematologic malignancies.
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Affiliation(s)
- Karen Lien
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Matthew C. Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin K.W. Chan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Knight C, Maciver F. The cost–effectiveness of rituximab in non-Hodgkin’s lymphoma. Expert Rev Pharmacoecon Outcomes Res 2014; 7:319-26. [DOI: 10.1586/14737167.7.4.319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tetteh E, Morris S. Systematic review of drug administration costs and implications for biopharmaceutical manufacturing. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2013; 11:445-456. [PMID: 23846573 DOI: 10.1007/s40258-013-0045-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND The acquisition costs of biologic drugs are often considered to be relatively high compared with those of nonbiologics. However, the total costs of delivering these drugs also depend on the cost of administration. Ignoring drug administration costs may distort resource allocation decisions because these affect cost effectiveness. OBJECTIVES The objectives of this systematic review were to develop a framework of drug administration costs that considers both the costs of physical administration and the associated proximal costs; and, as a case example, to use this framework to evaluate administration costs for biologics within the UK National Health Service (NHS). METHODS We reviewed literature that reported estimates of administration costs for biologics within the UK NHS to identify how these costs were quantified and to examine how differences in dosage forms and regimens influenced administration costs. The literature reviewed were identified by searching the Centre for Review and Dissemination Databases (DARE, NHS EED and HTA); EMBASE (The Excerpta Medica Database); MEDLINE (using the OVID interface); Econlit (EBSCO); Tufts Medical Center Cost Effectiveness Analysis (CEA) Registry; and Google Scholar. RESULTS We identified 4,344 potentially relevant studies, of which 43 studies were selected for this systematic review. We extracted estimates of the administration costs of biologics from these studies. We found evidence of variation in the way that administration costs were measured, and that this affected the magnitude of costs reported, which could then influence cost effectiveness. CONCLUSIONS Our findings suggested that manufacturers of biologic medicines should pay attention to formulation issues and their impact on administration costs, because these affect the total costs of healthcare delivery and cost effectiveness.
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Affiliation(s)
- Ebenezer Tetteh
- Department of Applied Health Research, EPSRC Centre for Innovative Manufacturing in Emergent Macromolecular Therapies, University College of London, 1-19 Torrington Place, London, WC1E 7HB, UK,
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Costo-efficacia di rituximab nella terapia di mantenimento in soggetti affetti da linfoma non-Hodgkin follicolare refrattario o recidivante. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/bf03320566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Johnston KM, Bolbocean C, Connors J, Peacock S. Cost-effectiveness of rituximab in follicular lymphoma. Expert Rev Pharmacoecon Outcomes Res 2012; 12:569-77. [PMID: 23140274 DOI: 10.1586/erp.12.57] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In advanced follicular lymphoma, rituximab is currently used with chemotherapy as induction therapy, and as maintenance monotherapy following induction in previously untreated patients and treatment-experienced relapsed/refractory patients. Herein, the authors characterize the clinical effectiveness, safety and cost-effectiveness of rituximab in follicular lymphoma, based on the literature review. Rituximab has a favorable safety profile and has been shown to improve progression-free survival, with some evidence of improvements to overall survival, particularly for relapsed/refractory patients. Rituximab has consistently been found to have a favorable economic profile, with cost per quality-adjusted life year falling within standard thresholds for cost-effectiveness. Challenges in cost-effectiveness analysis include the fact that life expectancy for patients with follicular lymphoma exceeds the period of available follow-up data and that treatment pathways are more complex than the model structures frequently used in oncology models. As data accrue and more complex models are developed, the cost-effectiveness of rituximab can be more accurately assessed.
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Affiliation(s)
- Karissa M Johnston
- Canadian Centre for Applied Research in Cancer Control, Vancouver, BC, Canada
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Whyte S, Cooper KL, Stevenson MD, Madan J, Akehurst R. Cost-effectiveness of granulocyte colony-stimulating factor prophylaxis for febrile neutropenia in breast cancer in the United Kingdom. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2011; 14:465-74. [PMID: 21669371 DOI: 10.1016/j.jval.2010.10.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Revised: 07/15/2010] [Accepted: 10/23/2010] [Indexed: 05/20/2023]
Abstract
OBJECTIVE We report a cost-effectiveness evaluation of granulocyte colony-stimulating factors (G-CSFs) for the prevention of febrile neutropenia (FN) after chemotherapy in the United Kingdom (UK). METHODS A mathematical model was constructed simulating the experience of women with breast cancer undergoing chemotherapy. Three strategies were modeled: primary prophylaxis (G-CSFs administered in all cycles), secondary prophylaxis (G-CSFs administered in all cycles after an FN event), and no G-CSF prophylaxis. Three G-CSFs were considered: filgrastim, lenograstim, and pegfilgrastim. Costs were taken from UK databases and utility values from published sources. A systematic review provided data on G-CSF efficacy. Probabilistic sensitivity analyses examined the effects of uncertainty in model parameters. RESULTS In the UK, base-case analysis with a willingness-to-pay (WTP) threshold of £20K per quality-adjusted life year gained and also using list prices, the most cost-effective strategy was primary prophylaxis with pegfilgrastim for a patient with baseline FN risk greater than 38%, secondary prophylaxis with pegfilgrastim for baseline FN risk 11% to 37%, and no G-CSFs for baseline FN risk less than 11%. Using a WTP threshold of £30K and list prices, primary prophylaxis with pegfilgrastim was cost-effective for baseline FN risks greater than 29%. In all analyses, pegfilgrastim dominated filgrastim and lenograstim. Sensitivity analyses demonstrated that higher WTP threshold, younger age, earlier stage at diagnosis, or reduced G-CSF prices result in G-CSF prophylaxis being cost-effective at lower baseline FN risk levels. CONCLUSION Pegfilgrastim was the most cost-effective G-CSF. The most cost-effective strategy (primary or secondary prophylaxis) was dependent on the FN risk level for an individual patient, patient age and stage at diagnosis, and G-CSF price.
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Delgado J, Febrer L, Nieves D, Piñol C, Brosa M. Análisis de minimización de costes de fludarabina (Beneflur®) oral vs. vía intravenosa en España. FARMACIA HOSPITALARIA 2009. [DOI: 10.1016/s1130-6343(09)72463-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Foster T, Miller JD, Boye ME, Russell MW. Economic burden of follicular non-Hodgkin's lymphoma. PHARMACOECONOMICS 2009; 27:657-679. [PMID: 19712009 DOI: 10.2165/11314820-000000000-00000] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Follicular non-Hodgkin's lymphoma (FNHL), a slow-growing cancer of the immune system, constitutes about 15-30% of all incident non-Hodgkin's lymphoma in developed countries. Its incidence is rising worldwide. Patients can live many years, but FNHL is considered incurable. We systematically reviewed the English-language MEDLINE-indexed and non-indexed economic literature published in the past 10 years on FNHL, identifying 23 primary economic studies. The economic burden of FNHL is significant, but available data are generally limited to retrospective considerations of hospital-based direct treatment costs, with little information available regarding societal cost of illness. Most direct cost information originates from the US, with one estimate of $US36 000 for the per-patient incremental cost of FNHL care during the first year following diagnosis. The most studied treatment is rituximab, which may offer similar overall costs to fludarabine considering higher resource use with fludarabine complications. Nearly all cost-effectiveness models identified by this review evaluated rituximab for relapsed/refractory FNHL responding to chemotherapy induction. Rituximab is supported as a cost-effective addition to standard chemotherapy by two models in the UK and one in the US, as maintenance therapy instead of stem-cell transplant by one UK model, and as maintenance therapy instead of observation alone by one model each in France, Spain and Canada. The UK National Institute for Health and Clinical Excellence updated guidance on rituximab in February 2008, concluding that it is cost effective when added to induction chemotherapy, and when used as maintenance therapy. No studies of per-patient or national indirect costs of illness were identified, with the only study of indirect costs a Canadian survey documenting lost work productivity. Across all study types identified by our review, the most common focus was on the direct costs of rituximab. As new treatments for FNHL come to market, more real-life cost data are imperative to calculate their relative cost effectiveness.
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Affiliation(s)
- Talia Foster
- Abt Bio-Pharma Solutions, Inc., Lexington, Massachusetts, USA.
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Ruger JP. Ethics in American health 2: an ethical framework for health system reform. Am J Public Health 2008; 98:1756-63. [PMID: 18703448 PMCID: PMC2636451 DOI: 10.2105/ajph.2007.121350] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2007] [Indexed: 12/29/2022]
Abstract
I argue that an ethical vision resting on explicitly articulated values and norms is critical to ensuring comprehensive health reform. Reform requires a consensus on the public good transcending self-interest and narrow agendas and underpinning collective action for universal coverage. In what I call shared health governance, individuals, providers, and institutions all have essential roles in achieving health goals and work together to create a positive environment for health. This ethical paradigm provides (1) reasoned consensus through a joint scientific and deliberative approach to judge the value of a health care intervention; (2) a method for achieving consensus that differs from aggregate tools such as a strict majority vote; (3) combined technical and ethical rationality for collective choice; (4) a joint clinical and economic approach combining efficiency with equity, but with economic solutions following and complementing clinical progress; and (5) protection for disabled individuals from discrimination.
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Affiliation(s)
- Jennifer Prah Ruger
- Yale University School of Medicine, Graduate School of Arts and Sciences, and Law School, 60 College St, PO Box 208034, New Haven, CT 06520-8034, USA.
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Otte A, Thompson SL. Practical and clinical benefits of radioimmunotherapy lead to advantages in cost-effectiveness in the treatment of patients with non-Hodgkin's lymphoma. Nucl Med Commun 2006; 27:753-6. [PMID: 16969255 DOI: 10.1097/01.mnm.0000224467.74545.27] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Schmitz S, Aly F, Steinmetz T, Diehl V, Rehwald U. Sensitivity analysis of cost factors for various therapy options in the treatment of follicular lymphoma. Oncol Res Treat 2006; 29:258-64. [PMID: 16770087 DOI: 10.1159/000093312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In Germany, patients with relapsed follicular non-Hodgkin's lymphoma do not all receive the same treatment. In this study, 3 therapy regimens were analyzed which were considered to be similar. With the goal of determining the treatment option with the lowest direct costs whilst maintaining the same degree of effectiveness, a cost analysis model was established and applied by way of example to the existing illness constellation. METHODS The German doctors' fee scale (Einheitlicher Bewertungsmassstab, EBM) valid until 2005 served as the basis for the calculation of medical services within the scope of the present statutory health insurance guidelines. A virtual standard patient was constructed for the cost model and treated with the different therapy regimens. The incidences of individual adverse events described in literature served as the basis for the characterization of the average toxicity of the respective treatment methods. RESULT The overall costs result from the sum of the treatment costs and the toxicity-related costs. The effect of additional interventions on the overall cost was also examined. CONCLUSION Whereas the accompanying documentation of costs in clinical studies is organizationally complex and very tedious, the model applied here offers a reliable method of quantifying the costs of the different therapy regimens. It permits the comparison of different treatment alternatives, and it enables, by means of a cost variance analysis, the identification of cost drivers and less expensive measures within a therapy method.
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Affiliation(s)
- Stephan Schmitz
- Hemato-Oncological Group Practice, University Hospital, Sachsenring 69, 50677 Cologne (Köln), Germany.
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Hutchinson J, Lloyd A, Gray A, Gale R, Hancock B. Costs of chemotherapy for indolent follicular non-Hodgkin's lymphoma in the UK: an observational study. Acta Haematol 2006; 115:28-34. [PMID: 16424646 DOI: 10.1159/000089462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2005] [Accepted: 07/14/2005] [Indexed: 11/19/2022]
Abstract
Non-Hodgkin's lymphoma (NHL) is the sixth most common cancer in the United Kingdom (UK). This analysis assessed the health service costs of patients receiving chemotherapy for indolent follicular NHL based on a retrospective analysis of patient records in the UK. Each patient was followed up for a period of 3 years or until death. The analysis included 181 patients, who received a total of 187 treatment periods. Costs were estimated from the perspective of the UK National Health Service. The study found the cost of providing treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) or fludarabine to patients with indolent follicular NHL to be lower than previously reported.
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Borbolla-Escoboza JR, Leon MI, Collados MT, Baez E, Baltasar S, Hernández R, Rojas JC. Induction of apoptosis and effect on CD20+ using rituximab on autologous peripheral blood stem cell harvests from patients with B cell lymphomas. Stem Cells Dev 2004; 13:193-6. [PMID: 15186735 DOI: 10.1089/154732804323046792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purging of neoplastic cells for autologous stem cell transplantation is usually done in vivo by administering chemotherapy and/or other agents before harvesting. It is also possible to decrease malignant cells counts directly in the cell harvest. In this study, we ascertained the effect of anti-CD20 monoclonal antibody and rituximab administration on peripheral blood hematopoietic stem cells. Five samples of stem cell harvests from different patients with B cell lymphoma were obtained. Each sample was divided in two tubes with calcium gluconate (20 mEq/50 microl). Rituximab (1 mg/600,000 mononuclear cells) was added to one of the tubes. Using flow cytometry, CD19, CD20 (B cell markers), and CD95 (apoptosis marker), expression was measured at baseline and 24 h after the addition of rituximab. A one-sided t-test with equal variances was used to analyze the results. Immediately after rituximab addition, CD20 expression became null. No significant difference in variation of CD19 expression was detected after the addition of rituximab (-3.64% control vs. 0.63% rituximab, p = 0.69). Mean variations of percentage of CD95 expression were 2.9% (controls) and 10.52% (rituximab tubes) (p = 0.06). We conclude that rituximab is capable of initiating apoptosis in vitro. We found no decrease in the CD19+ cell count, used as a surrogate marker for CD20+ cells, meaning that, at least in 24 h, apoptosis activation is not capable of decreasing CD20+ cell numbers. In vitro purging of peripheral blood stem cells harvests with rituximab could be part of a broader therapeutic strategy to be offered to lymphoproliferative disorder patients.
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Plosker GL, Figgitt DP. Rituximab: a review of its use in non-Hodgkin's lymphoma and chronic lymphocytic leukaemia. Drugs 2003; 63:803-43. [PMID: 12662126 DOI: 10.2165/00003495-200363080-00005] [Citation(s) in RCA: 343] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Rituximab is an anti-CD20 monoclonal antibody that has demonstrated efficacy in patients with various lymphoid malignancies, including indolent and aggressive forms of B-cell non-Hodgkin's lymphoma (NHL) and B-cell chronic lymphocytic leukaemia (CLL). While the optimal use of the drug in many clinical settings has yet to be clarified, two pivotal trials have established rituximab as a viable treatment option in patients with relapsed or refractory indolent NHL, and as a standard first-line treatment option when combined with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) chemotherapy in elderly patients with diffuse large B-cell lymphoma (the most common type of aggressive NHL). The former was a noncomparative trial in relapsed indolent NHL (follicular and small lymphocytic subtypes) with clinical responses achieved in about half of patients treated with rituximab 375 mg/m(2) intravenously once weekly for 4 weeks, which was similar to some of the most encouraging results reported with traditional chemotherapeutic agents. The latter was a randomised comparison of eight cycles of CHOP plus rituximab 375 mg/m(2) intravenously (one dose per cycle) versus CHOP alone in previously untreated elderly patients (60 to 80 years of age) with diffuse large B-cell lymphoma. In this pivotal trial, 2-year event-free and overall survival were significantly higher with rituximab plus CHOP, and there was no increase in clinically significant adverse effects compared with CHOP alone. Treatment with rituximab is generally well tolerated, particularly in terms of adverse haematological effects and serious or opportunistic infections relative to standard chemotherapy. Infusion-related reactions occur in the majority of patients treated with rituximab; these are usually mild to moderate flu-like symptoms that decrease in frequency with subsequent infusions. In approximately 10% of patients, however, severe infusion-related reactions develop (e.g. bronchospasm, hypotension). These reactions are usually reversible with appropriate interventions and supportive care but there have been rare reports of fatalities. CONCLUSIONS Clinical trials with rituximab indicate that the drug has broad application to B-cell malignancies, although further clarification is needed to determine its optimal use in many of these clinical settings. Importantly, rituximab in combination with CHOP chemotherapy has emerged as a new treatment standard for previously untreated diffuse large B-cell lymphoma, at least in elderly patients. Compared with conventional chemotherapy, rituximab is associated with markedly reduced haematological events such as severe neutropenia, as well as associated infections. Rituximab may be particularly suitable for elderly patients or those with poor performance status, and its tolerability profile facilitates its use in combination with cytotoxic drugs. PHARMACODYNAMIC PROPERTIES Rituximab is a mouse/human chimaeric IgG(1)-kappa monoclonal antibody that targets the CD20 antigen found on the surface of malignant and normal B lymphocytes. Although treatment with rituximab induces lymphopenia in most patients, typically lasting about 6 months, a full recovery of B lymphocytes in the peripheral blood is usually seen 9-12 months after therapy, as CD20 is not expressed on haematopoietic stem cells. CD20 is, however, expressed on >90% of B-cell non-Hodgkin's lymphomas (NHL) and to a lesser degree on B-cell chronic lymphocytic leukaemia (CLL) cells. Although not fully elucidated, the cytotoxic effects of rituximab on CD20-positive malignant B cells appears to involve complement-dependent cytotoxicity, complement-dependent cellular cytotoxicity, antibody-dependent cellular cytotoxicity and induction of apoptosis. In addition, in vitro data indicate that rituximab sensitises tumour cells to the effects of conventional chemotherapeutic drugs. PHARMACOKINETIC PROPERTIES Serum rituximab concentrations increased in proportion to dose across a wide range of single- and multiple-dose intravenous regimens in patients with B-cell NHL. When administll NHL. When administered at a dose of 375 mg/m(2) once weekly for 4 weeks in a pivotal trial in patients with relapsed or refractory indolent B-cell NHL (follicular or small lymphocytic subtypes), peak serum concentrations essentially doubled from the first (239.1 mg/L) to the fourth (460.7 mg/L) infusion, while elimination half-life (t(1/2)) increased from 76.3 to 205.8 hours (3.2 to 8.6 days). The concomitant increase in serum rituximab concentrations and t(1/2) with each successive infusion may be due, at least in part, to the elimination of circulating CD20-positive B cells and reduction or saturation of CD20-binding sites after the initial infusions of rituximab. The pharmacokinetic properties of rituximab are also characterised by wide inter-individual variability, and serum drug concentrations that are correlated with clinical response. Although pharmacokinetic data are limited in patients with aggressive forms of NHL, such as diffuse large B-cell lymphoma, rituximab appears to have a similar pharmacokinetic profile in these patients to that in patients with indolent B-cell NHL. The pharmacokinetics of rituximab are also reported to be similar whether the drug is administered with or without cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) chemotherapy. THERAPEUTIC USE A number of studies have demonstrated efficacy of intravenous rituximab in patients with various lymphoid malignancies of B-cell origin, including indolent (e.g. follicular lymphoma) and aggressive (e.g. diffuse large B-cell lymphoma) forms of NHL, and CLL, but the drug has not yet been approved for use in CLL, and approved indications in NHL vary between countries. In the US, for example, rituximab is available for the treatment of patients with low-grade or follicular, relapsed or refractory, CD20-positive B-cell NHL. In Europe, the drug has similar approval for relapsed or refractory follicular NHL as in the US, but has also been approved for use in combination with CHOP chemotherapy for the most common aggressive form of NHL (CD20-positive, diffuse large B-cell lymphoma). Rituximab was approved for these indications primarily on the basis of results from two pivotal trials. In Japan, rituximab has been approved for indolent B-cell NHL and mantle cell lymphoma (an aggressive form of B-cell NHL), primarily on the basis of results of a Japanese phase II trial. Indolent NHL: Results of several studies evaluating rituximab 375 mg/m(2) once weekly for 4 weeks in patients with indolent forms of B-cell NHL (primarily follicular and small lymphocytic lymphomas) showed objective response (OR) rates ranging from approximately 40-60% in those receiving the drug for relapsed or refractory indolent B-cell NHL, and slightly higher (50-70%) for those receiving rituximab as first-line therapy. In a pivotal trial in 166 patients with relapsed or refractory low-grade or follicular B-cell NHL, intent-to-treat (ITT) analysis showed an OR rate of 48%, and a projected median time to progression of 13 months. Encouraging data are also emerging on the use of rituximab in combination with chemotherapeutic agents (e.g. CHOP, fludarabine-containing regimens) or other drugs (e.g. interferon-alpha2a) in previously untreated patients with indolent forms of B-cell NHL (primarily follicular and small lymphocytic subtypes). Rates for OR were consistently around 95%, with the majority being complete responses (CRs). Follow-up data from a study in 40 patients with low-grade or follicular B-cell NHL treated with rituximab plus CHOP as first-line therapy showed that responses were durable with a progression-free survival and median duration of response >5 years.Bcl-2 gene rearrangement (t14;18) occurs in malignant cells in up to 85% of patients with follicular lymphoma, and minimal residual disease in peripheral blood and bone marrow can be monitored using polymerase chain reaction (PCR). In several studies assessing blood and/or bone marrow, rituximab has achieved molecular response (conversion from PCR-positive to PCR-negative bcl-2 status) in at least half of the patients. Aggressive NHL: Studies with rituximab as monotherapy in aggressive B-cell NHL, a potentially curable disorder, have generally been restricted to patients with relapsed or recurrent disease, since CHOP has traditionally been the standard first-line treatment regimen. However, promising results from phase II monotherapy studies prompted further clinical investigation of rituximab in conjunction with chemotherapy. Thus, most studies with rituximab in patients with aggressive forms of B-cell NHL have involved combination therapy, including a pivotal randomised trial comparing eight cycles of standard CHOP therapy plus rituximab 375 mg/m(2) (one dose per cycle) versus CHOP alone in 399 previously untreated elderly patients (60-80 years of age) with diffuse large B-cell lymphoma. Results of the pivotal trial showed a clear advantage for rituximab plus CHOP versus CHOP in terms of event-free survival (primary endpoint) at 2 years (57% vs 38%, p < 0.001). Overall survival at 2 years (70% vs 57%, p < 0.01) and CR rate (76% vs 63%, p < 0.01) were also higher with the rituximab-CHOP combination. Other, smaller trials with rituximab in combination with CHOP or other chemotherapeutic regimens, either as first-line therapy or for patients with relapsed or refractory aggressive B-cell NHL, have also shown promising results in terms of clinical response rates.CLL: In relatively small trials (n < 40) conducted primarily in patients with relapsed or refractory B-cell CLL, rituximab monotherapy (various regimens) achieved OR rates of 23-45%, with median duration of response ranging from approximately 3-10 months. (ABSTRACT TRUNCATED)
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Affiliation(s)
- Greg L Plosker
- Adis International Limited, Mairangi Bay, Auckland, New Zealand.
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Newby D, Hill S. Use of pharmacoeconomics in prescribing research. Part 2: cost-minimization analysis--when are two therapies equal? J Clin Pharm Ther 2003; 28:145-50. [PMID: 12713612 DOI: 10.1046/j.1365-2710.2003.00455.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED This is the second paper in a series looking at pharmacoeconomic methods. The first paper discussed how costs are identified for pharmacoeconomic studies. This article will examine one of the four main evaluation methods in health economics, cost-minimization analysis (CMA). The remaining three methods (cost-effectiveness, cost-utility and cost-benefit analysis) will be discussed in later papers. KEY MESSAGES Cost-minimization is the appropriate form of economic analysis to carry out whenever two drugs have the same clinical effect. True equivalence studies are uncommon; a more useful approach is to assess the size of the confidence interval around the difference between treatments and determine whether it excludes clinically relevant effects. The critical issue for cost-minimization analyses is determining equi-effective doses.
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Affiliation(s)
- D Newby
- Clinical Pharmacology, School of Medical Practice and Population Health, Faculty of Health, University of Newcastle NSW, Australia.
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Herold M, Hieke K. Costs of drug delivery for CHOP, COP/CVP, and fludarabine: an international assessment. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2003; 6:167-174. [PMID: 12641867 DOI: 10.1046/j.1524-4733.2003.00227.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVES The purpose of this analysis was to assess the real-life direct costs of drug delivery for frequently used chemotherapeutic regimens in patients with relapsed low-grade non-Hodgkin's lymphoma (NHL). METHODS This was a retrospective analysis of direct costs of drug delivery (acquisition plus administration) of relapsed low-grade NHL in 424 patients in Canada, Germany, and Italy. Results were expressed as an average treatment cost per patient for six cycles of chemotherapy. Exchange rates used were $1 (Canada)= currency 0.672, 1 DM (Germany)= currency 0.511, and 1 Lit (Italy)= currency 0.000517. RESULTS Direct costs of drug delivery were greater for inpatients receiving fludarabine (Canada currency 12,669; Italy currency 13,027) than for CHOP (Canada currency 7856; Germany currency 7218; Italy currency 4251) or COP/CVP (Canada currency 7360; Germany currency 8449). Treatment administration setting was a major cost driver with inpatient treatment up to 9-fold more expensive than the same regimen given to outpatients. Drug administration costs comprised the largest proportion of the total for each regimen in the inpatient setting (69-98%). Costs of drug delivery in the outpatient setting were 10% to 65% of those in the inpatient setting. Again, fludarabine was more expensive (Italy currency 8493; Canada currency 7269) than CHOP (Canada currency 4403; Germany currency 2150; Italy currency 1264) and COP/CVP (Canada currency 3009; Germany currency 867). Administration costs were 2.5- to 15-fold higher for inpatients compared to outpatients. CONCLUSIONS Costs of drug administration are a major driver for total direct treatment costs in the treatment of relapsed low-grade NHL and are at least as important as drug acquisition costs. Drug administration practices, in terms of inpatient or outpatient treatment, are a major factor in determining overall direct costs. Therapeutic strategies, which offer shortened treatment duration and/or a simple mode of administration, are likely to be economically attractive.
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Klepfish A, Schattner A, Shvidel L, Shtalrid M, Haran M, Bentwich Z, Berrebi A. Successful treatment of aggressive HIV-associated non-Hodgkin's lymphoma with combination chemotherapy, biotherapy with rituximab and HAART: presentation of a therapeutic option. Leuk Lymphoma 2003; 44:349-51. [PMID: 12688356 DOI: 10.1080/1042819031000060537] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The incidence of non-Hodgkin's lymphoma (NHL) in individuals infected with human immunodeficiency virus (HIV) is more than 60 times higher than in matched controls. In the vast majority of cases aggressive pathological subtypes and advanced stages prevail, extranodal sites are involved and systemic symptoms are present. The prognosis of HIV-NHL remains poor and the optimal therapeutic approach has yet to be defined. We report a 48-year-old Ethiopian woman with advanced-stage HIV infection, who developed diffuse large cell, immunoblastic type B-cell NHL and was treated with a modified CHOP-like chemotherapy combined with Rituximab and supported with growth factor. Highly active antiretroviral therapy (HAART) and opportunistic infections prophylaxis were administered concomitantly. The patient completed 6 cycles of therapy and currently, 76 weeks after diagnosis, is in complete clinical remission. Despite the fact that there was a transient decrease in the CD4-positive cell number and a 1.5 log increase in plasma viral load there were no opportunistic infections, nor was life-threatening toxicity seen. Rituximab seems a well-tolerable and advantageous adjunct to chemotherapy and HAART in the treatment of aggressive HIV-associated NHL andshould be investigated in large trials in the future.
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MESH Headings
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antiretroviral Therapy, Highly Active
- Female
- Humans
- Lymphoma, AIDS-Related/drug therapy
- Lymphoma, AIDS-Related/pathology
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/virology
- Opportunistic Infections/prevention & control
- Remission Induction
- Rituximab
- Viral Load
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Affiliation(s)
- A Klepfish
- Hematology Institute, Kaplan Medical Center, Rehovot, Israel.
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Coiffier B. Rituximab in combination with CHOP improves survival in elderly patients with aggressive non-Hodgkin's lymphoma. Semin Oncol 2002; 29:18-22. [PMID: 12040530 DOI: 10.1053/sonc.2002.32749] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Diffuse large B-cell lymphoma (DLCL) is the most frequently diagnosed subtype of non-Hodgkin's lymphoma (NHL), and more than 50% of cases present in patients over 60 years of age. Although cyclophosphamide/doxorubicin/vincristine/prednisone (CHOP) is currently regarded as the gold standard treatment for DLCL, less than half of the elderly patients treated are cured. Therefore, it is essential that new strategies are developed. Rituximab is a chimeric monoclonal antibody that is directed against the B-cell-specific antigen CD20 that is expressed on 80% of NHLs. Pilot trials combining rituximab with CHOP have suggested an efficacy advantage in both indolent and aggressive B-cell NHL, with no significant impact on toxicity. The Groupe d'Etude des Lyphomes de l'Adulte LNH-98.5 trial is the first randomized clinical trial to compare rituximab plus CHOP with CHOP alone in lymphoma patients. The trial compared the two treatment regimens in elderly patients with aggressive DLCL. Interim data (18-month follow-up) from this trial showed that the addition of rituximab to CHOP results in a statistically superior benefit in survival compared with CHOP alone. These groundbreaking data are the first in 20 years to show statistical improvement over CHOP and this suggests that rituximab plus CHOP may become the new gold standard treatment for elderly patients with DLCL.
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Abstract
The nucleoside analogues are a group of antimetabolite cytotoxics which generally have to be metabolised to the equivalent nucleotide before incorporation into DNA. Cytarabine is a well established component of the treatment of acute leukaemias and has its principal action on dividing cells. New formulations include a liposome encapsulated product for intrathecal use and oral cytarabine ocfosfate which may be suitable for long-term outpatient use. Pentostatin acts by causing accumulation of deoxynucleotides and, although active against hairy cell leukaemia, is associated with a poor tolerance profile. Cladribine and fludarabine have substantial activity in the treatment of chronic lymphocytic leukaemia (CLL) and low-grade non-Hodgkin's lymphoma (NHL). Fludarabine is the more thoroughly investigated of the two and is currently being developed in combination therapies for CLL and NHL and also in a combination with cytarabine for acute myeloid leukaemia. Fludarabine's immunosuppressive activity is being exploited in the conditioning of patients for non-myeloablative stem cell transplantation. Gemcitabine is an established agent in the treatment of a number of solid tumours but also has activity in haematological malignancies which might be exploited by the use of extended infusion schedules. Newer agents including nelarabine, clofarabine and troxacitabine are undergoing clinical evaluation and show promising activity.
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Affiliation(s)
- S A Johnson
- Dept.of Haematology, Taunton & Somerset Hospital, UK
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