Cost-effectiveness analysis of inhaled corticosteroids in asthma: a review of the analytical standards

Economic evidence for nonpharmacological asthma management interventions: A systematic review

Asthma management, education and environmental interventions have been reported as cost‐effective in a previous review (Pharm Pract (Granada), 2014;12:493), but methods used to estimate costs and outcomes were not discussed in detail. This review updates the previous review by providing economic evidence on the cost‐effectiveness of studies identified after 2012, and a detailed assessment of the methods used in all identified studies. Twelve databases were searched from 1990 to January 2016, and studies included economic evaluations, asthma subjects and nonpharmacological interventions written in English. Sixty‐four studies were included. Of these, 15 were found in addition to the earlier review; 53% were rated fair in quality and 47% high. Education and self‐management interventions were the most cost‐effective, in line with the earlier review. Self‐reporting was the most common method used to gather resource‐use data, accompanied by bottom‐up approaches to estimate costs. Main outcome measures were asthma‐related hospitalizations (69%), quality of life (41%) and utility (38%), with AQLQ and the EQ‐5D being the most common questionnaires measured prospectively at fixed time points. More rigorous costing methods are needed with a more common quality of life tool to aid greater replicability and comparability amongst asthma studies.

Cost-effectiveness of budesonide/formoterol maintenance and rescue therapy in Thailand

Background: The prevalence of asthma has increased significantly in Thailand. Budesonide/formoterol maintenance and reliever therapy has been available for several years. However, cost-effectiveness of such treatment has never been examined in Thailand. Objective: Design a cost-effectiveness (CE) analysis conducted from a Thai healthcare perspective as a piggyback study accompanying a recent clinical trial. Methods: The CE analysis was conducted from the healthcare provider’s perspective. Data were collected from a six-month, double-blind, multi-national study involving 3321 symptomatic asthma patients randomized to either: bud/form maintenance and reliever therapy, bud/form 320/9 μg bid plus terbutaline as needed, or salmeterol/ fluticasone (salm/flut) 25/125 μg two inhalations bid plus terbutaline as needed. Efficacy was determined as the number of exacerbations per patient during a six-month period. Thai unit costs were collected from the national sources and expert opinions, and applied to the resource use data for a deterministic economic evaluation. Results: There were significantly fewer exacerbations in the bud/form maintenance and reliever therapy (0.12 events/patient/6 months) group vs. the bud/form (0.16 events/patient/6 months, p <0.01), or salm/flut groups (0.19 events/patient/6 months, p <0.001). Total direct costs (healthcare visits and drug costs) were 27.0% and 5.9% lower in the bud/form maintenance and reliever therapy group than in the bud/form and salm/flut groups, respectively. Conclusion: Bud/form maintenance and reliever therapy was associated with significantly fewer exacerbations, compared to other fixed combination treatments in a recent multi-national clinical trial. This might result in lower direct costs if applied to the Thai healthcare system.

Sodium cromoglycate alone and in combination with montelukast on the airway response to mannitol in asthmatic subjects

BACKGROUND

Mannitol, inhaled as a dry powder, is used for bronchial provocation to identify bronchial hyperresponsiveness. Bronchoconstriction is associated with an increase in urinary excretion of the metabolites of prostaglandin D(2) and leukotriene E(4). Sodium cromoglycate provides about 60% protection against the fall in forced expiratory volume in one second (FEV(1)) provoked by inhaled mannitol and appears to do so by inhibiting the release of prostaglandin D(2) but not leukotriene E(4).The leukotriene receptor antagonist montelukast does not alter sensitivity to mannitol, as measured by the provoking dose to cause a 15% fall in FEV(1) to mannitol, but it significantly enhances recovery from the bronchoconstriction provoked by mannitol.

OBJECTIVE

The authors proposed that the combination of these two drugs would be superior to sodium cromoglycate alone and result in greater protection from the bronchoconstriction provoked by mannitol.

METHODS

The % fall in FEV(1) from baseline and the area under the 30-min FEV(1) time curve and time to recover to 95% baseline FEV(1) were used to express protection from 40 mg sodium cromoglycate alone, and in combination with 10 mg montelukast, in subjects with asthma. Mannitol was inhaled in the dose that caused a 20% fall in FEV(1) on the screening day. The prechallenge medications were randomised on the 3 treatment days and were (1) placebo sodium cromoglycate and placebo montelukast; (2) sodium cromoglycate and placebo montelukast; and (3) sodium cromoglycate and montelukast.

RESULTS

The protection by sodium cromoglycate alone on the % fall in FEV(1) was 64.4% +/- 21.0% versus 65.8% +/- 62.8% (p = NS) on the combination. The protection on the area under the 30-min FEV(1) time curve for sodium cromoglycate was 81.8% +/- 14.0% (p <.04) and 89.3% +/- 9.8% for the combination (p <.001) compared with placebo. Recovery to 95% baseline FEV(1) by 5/10 min occurred in 58%/66% of subjects on sodium cromoglycate and 66%/83% on the combination compared with 0%/0% on placebo.

CONCLUSION

The addition of montelukast to sodium cromoglycate provided only a small additional benefit against the airway response to mannitol.

[Inhaled corticosteroids in asthma: a medico-economic analysis of clinical trials]

BACKGROUND

Asthma is a chronic disease with a heavy economic burden in terms of public health on account of its clinical impact and consequences on quality of life and costs. Its management is based on pharmacological measures with inhaled corticosteroids playing a large role. The objective of this study was to undertake an analysis of the published literature of medico-economic trials of the use of inhaled corticosteroids.

METHODS

A review of the literature from 1990 to 2007 was undertaken with separate analyses of studies of inhaled steroids alone and those looking at combined preparations.

RESULTS

The costs of asthma vary greatly depending on the clinical management. Analysis of the published clinical trials showed that the addition of inhaled steroids increased the total cost. When efficacy is taken into account the economic results are acceptable for developed societies. The use of inhaled steroids as maintenance therapy, or maintenance and symptomatic therapy, was always cost effective.

CONCLUSION

These results are based on data from clinical trials. They need to be confirmed by large scale observational studies using validated criteria of effectiveness.

Single-inhaler combination therapy for asthma: a review of cost effectiveness

Clinical studies have shown that the combination of an inhaled corticosteroid (ICS) and a long-acting beta(2)-adrenoceptor agonist (LABA) for patients with asthma is more effective than the use of ICS alone in equivalent or higher doses, as well as the use of other combinations. However, the relatively higher acquisition costs for the combination therapy require assessment of the value of the incremental costs, especially from a societal perspective. This review provides an overall assessment of the cost effectiveness of ICS plus LABA combination therapy for asthma. A systematic literature research was conducted in MEDLINE to identify studies published between January 1994 and September 2005. Cost-effectiveness studies derived from 11 clinical studies were identified. The ICS plus LABA combination was compared with ICS alone in eight studies, ICS plus a leukotriene antagonist in two studies, and a leukotriene antagonist alone in one study. All studies focused on measuring direct medical costs in a total of six different healthcare systems, and three studies conducted sensitivity analyses, including productivity costs. Outcomes were measured in treatment success (changes in lung function), episode-free days, and symptom-free days by evaluating short-term follow-up. The combination of ICS and LABA was found to be more efficacious and cost effective compared with ICS alone or alternative combinations of controller medications. Further considerations for measuring long-term outcomes and dose-response relationships might be required to provide further evidence on the cost effectiveness of combination therapy with ICS plus LABA.

Asthma economics: focusing on therapies that improve costly outcomes

PURPOSE OF REVIEW

In 1998, the economic burden of asthma was estimated to be 12.7 billion dollars. Subsequent research has focused on identifying important outcomes that reflect high resource utilization and finding therapies that improve these outcomes and decrease cost. Recent developments include an update to the National Heart, Lung, and Blood Institute (NHLBI) guidelines, new treatment strategies using combination therapy, and the development of a monoclonal antibody therapy for asthma.

RECENT FINDINGS

Two important costly outcomes are asthma-related hospitalizations and emergency department visits. Asthma-related hospitalizations started to decline in the 1990s, primarily in white Americans, but not in young African Americans. Many hospitalizations and emergency department visits are preventable, and costs were lowered by shifting management to the ambulatory care setting. Increased asthma severity and suboptimal compliance with NHLBI asthma care guidelines can contribute to the persistence of symptoms, which triggers behaviors that increase resource utilization.A recent economic analysis was one of the first well-controlled clinical trials to show that inhaled corticosteroids provide clinical benefit at modest costs. Combination therapy, particularly that containing an inhaled corticosteroid and long-acting bronchodilator in a single inhaler, potentially can reduce overall costs by improving compliance with inhaled corticosteroids. Nonpharmacologic therapies also have been shown to be cost-effective. However, a significant number of patients with asthma continue to have symptoms even while on recommended controller therapy. Omalizumab, a monoclonal antibody treatment that binds IgE, was released in the summer of 2003.

SUMMARY

Many costly asthma-related hospitalizations and emergency department visits are preventable, and chronic disease care can be shifted to the ambulatory setting. Increased asthma severity and noncompliance with NHLBI guidelines are associated with increased resource utilization. Combination therapies can assist in improving patient compliance, and omalizumab potentially offers a novel but expensive way to decrease symptoms and resource utilization.

Cost-effectiveness of formoterol and salbutamol as asthma reliever medication in Sweden and in Spain

This study aimed to evaluate the cost-effectiveness of formoterol (Oxis) Turbuhaler 4.5 microg and salbutamol 200 microg as reliever medications in Sweden and Spain. The study used data on effectiveness (exacerbations and symptom-free days) and resource utilisation from an open, 6-month, parallel-group, multicentre randomised trial with 18,124 asthma patients in 24 countries. Country-specific unit costs for Sweden and for Spain were used to transform resource utilisation data into costs. Total healthcare costs were not significantly different between formoterol and salbutamol dry powder inhalers in Sweden, whereas in Spain, the healthcare costs were 20% higher for formoterol vs. salbutamol pressurised metered dose inhalers. Total healthcare costs increased with disease severity, defined according to the Global Initiative for Asthma guidelines. Compared with salbutamol, formoterol produced statistically significant improvements in effectiveness, less reliever and maintenance medication usage, reduced healthcare resource utilisation, with no increase or a limited increase in healthcare cost.