Cost-Effectiveness Analysis of Genotype-Guided Treatment Allocation in Patients with Alcohol Use Disorders Using Naltrexone or Acamprosate, Using a Modeling Approach

The use of health utility in cost-utility analysis: A systematic review in substance use disorders

BACKGROUND AND AIM

We aim to identify within-trial and modelled Cost-Utility Analysis (CUA) in substance use disorders (SUD) and review the applicability assessment associated with health utility used in modelled CUA.

STUDY DESIGN AND METHODS

We searched Medline, Embase, EconLit and the Pharmaceutical Benefits Advisory Committee (PBAC) databases. A global systematic literature search was undertaken to determine the CUA of SUD interventions. Key characteristics of the studies and use of health utility were described. The applicability assessment associated with health utility used in modelled CUA was reviewed using The Health Utility Application Tool (HAT).

RESULTS

The final review retrieved 49 CUA (14 within-trial and 35 modelled CUA). Three major health utility measurements were used - standard gamble, EQ-5D-5L and SF-6D. EQ-5D-5L was mainly used in within-trial CUA, whereas standard gamble, EQ-5D-5L and SF-6D were equally cited in modelled CUA and within-trial CUA. Twenty-nine articles using modelled CUA citing health utilities from published literature were assessed. Only half and one-third of CUA studies described the type of quality-of-life measure and value sets used in health utility studies, respectively. Only two-thirds showed the authors addressed questions about the similarities in clinical conditions, and health state description between health utility studies and economic evaluation studies.

CONCLUSION

Justifications for chosen health utilities in modelled CUA studies were mostly absent in SUD. We suggested health economists use the HAT to make judgements when assessing health utility from published estimates. The use of this tool will increase the reliability of economic evaluation carried out to assist government and policymakers in making informed decisions around health topics.

Haplotype phasing of CYP2D6: an allelic ratio method using Agena MassARRAY data

Pharmacogenomics aims to use the genetic information of an individual to personalize drug prescribing. There is evidence that pharmacogenomic testing before prescription may prevent adverse drug reactions, increase efficacy, and reduce cost of treatment. CYP2D6 is a key pharmacogene of relevance to multiple therapeutic areas. Indeed, there are prescribing guidelines available for medications based on CYP2D6 enzyme activity as deduced from CYP2D6 genetic data. The Agena MassARRAY system is a cost-effective method of detecting genetic variation that has been clinically applied to other genes. However, its clinical application to CYP2D6 has to date been limited by weaknesses such as the inability to determine which haplotype was present in more than one copy for individuals with more than two copies of the CYP2D6 gene. We report application of a new protocol for CYP2D6 haplotype phasing of data generated from the Agena MassARRAY system. For samples with more than two copies of the CYP2D6 gene for which the prior consensus data specified which one was present in more than one copy, our protocol was able to conduct CYP2D6 haplotype phasing resulting in 100% concordance with the prior data. In addition, for three reference samples known to have more than two copies of CYP2D6 but for which the exact number of CYP2D6 genes was unknown, our protocol was able to resolve the number for two out of the three of these, and estimate the likely number for the third. Finally, we demonstrate that our method is applicable to CYP2D6 hybrid tandem configurations.

Economic evaluations of alcohol pharmacotherapy: Systematic review of economic evaluations of pharmacotherapy for the treatment of alcohol use disorder

OBJECTIVE

Alcohol use disorders confer a significant burden of disease and economic cost worldwide. However, the utilisation of pharmacotherapies to manage alcohol use disorder is poor. We aimed to conduct a systematic review of economic evaluation studies of alcohol use disorder pharmacotherapies.

METHODS

A search was conducted in Embase, Medline, CINAHL, PsychINFO and EconLit (August 2019, updated September 2022). Full economic evaluations using pharmacotherapy to treat alcohol use disorders were included. Included studies were stratified by medication and summarised descriptively. The Consensus on Health Economic Criteria list was used to assess the methodological quality.

RESULTS

A total of 1139 studies were retrieved, of which 15 met the inclusion criteria. All studies were conducted in high-income countries. Four studies analysed nalmefene, four studies assessed acamprosate, three for naltrexone and four for stand-alone and/or combinations of naltrexone and acamprosate. There were 21 interventions synthesised from 15 studies as some studies evaluated multiple interventions and comparators. More than half of the included studies (73%) reported pharmacotherapy as dominant (less costly and more effective than comparators). From healthcare payer perspectives, five studies found that pharmacotherapy added to psychosocial support was dominant or cost-effective, accruing additional benefits at a higher cost but under accepted willingness to pay thresholds. Three analyses from a societal perspective found pharmacotherapy added to psychosocial support was a dominant or cost-effective strategy. Quality scores ranged from 63% to 95%.

CONCLUSION

Pharmacotherapy added to psychosocial support was cost-effective from both healthcare and societal perspectives, emphasising an increased role for pharmacotherapy to reduce the burden of alcohol use disorders.

Assessing the utility of measurement methods applied in economic evaluations of pharmacogenomics applications

An increasing number of economic evaluations are published annually investigating the economic effectiveness of pharmacogenomic (PGx) testing. This work was designed to provide a comprehensive summary of the available utility methods used in cost-effectiveness/cost-utility analysis studies of PGx interventions. A comprehensive review was conducted to identify economic analysis studies using a utility valuation method for PGx testing. A total of 82 studies met the inclusion criteria. A majority of studies were from the USA and used the EuroQol-5D questionnaire, as the utility valuation method. Cardiovascular disorders was the most studied therapeutic area while discrete-choice studies mainly focused on patients' willingness to undergo PGx testing. Future research in applying other methodologies in PGx economic evaluation studies would improve the current research environment and provide better results.

Economic Impact of the Application of a Precision Medicine Model (5SPM) on Psychotic Patients

BACKGROUND

Schizophrenia is a severe mental disorder that often manifests within the first three decades of life. Its prognosis is uncertain and may result in a prolonged treatment that could extend throughout the entire lifespan of the patient. Antipsychotic drugs are characterized by a high interindividual variability when considering therapeutic effect and emergence of adverse effects. Such interindividual variability is thought to be associated primarily with pharmacokinetic matters.

OBJECTIVE

The objective of this study was to evaluate the economic impact of the application of the 5-Step Precision Medicine model (5SPM), an approach based on the pharmacogenetic analysis of the primary genes involved in the metabolism of the therapy for each patient, restructuring treatment as necessary.

PATIENTS AND METHODS

One hundred eighty-eight psychiatry patients were analysed for single nucleotide polymorphisms on genes CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP3A5 and ABCB1. Information on patients' diagnosis, pharmacotherapy, and hospitalizations was collected.

RESULTS

We achieved a cost-benefit ratio of 3.31-3.59 with a reduction of direct cost (hospitalizations plus pharmacotherapy) with a reduction of total cost in 67% of the patients who underwent the clinical intervention.

CONCLUSION

A rational Precision Medicine-based approach to psychiatric patients could result in a reduction on number of drugs required to control exacerbations, and the underlying pathologies, reducing the risk of adverse effects and improving adherence to treatment, leading to a potential decrease in direct costs. This methodology has been shown to be cost-dominant and, being based on a pharmacogenetic analysis, it has a lifelong nature, as the data obtained can be applied to other medical disciplines.

Endogenous Opiates and Behavior: 2018

This paper is the forty-first consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2018 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (2), the roles of these opioid peptides and receptors in pain and analgesia in animals (3) and humans (4), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (5), opioid peptide and receptor involvement in tolerance and dependence (6), stress and social status (7), learning and memory (8), eating and drinking (9), drug abuse and alcohol (10), sexual activity and hormones, pregnancy, development and endocrinology (11), mental illness and mood (12), seizures and neurologic disorders (13), electrical-related activity and neurophysiology (14), general activity and locomotion (15), gastrointestinal, renal and hepatic functions (16), cardiovascular responses (17), respiration and thermoregulation (18), and immunological responses (19).

Alcohol use disorder relapse factors: A systematic review

A relapsing-remitting course is very common in patients with an Alcohol Use Disorder (AUD). Understanding the determinants associated with alcohol resumption remains a formidable task. This paper examines relapse determinants based on a systematic review of recent alcohol literature (2000-2019). Relevant databases were consulted for articles that contained information about specific relapse determinants and reported statistical significance of each relapse determinant in predicting relapse. Relapse was broadly defined based on the characterization in the included articles. From the initial identified 4613 papers, a total of 321 articles were included. Results encompass multiple relapse determinants, which were ordered according to biopsychosocial and spiritual categories, and presented, using a descriptive methodology. Psychiatric co-morbidity, AUD severity, craving, use of other substances, health and social factors were consistently significantly associated with AUD relapse. Conversely, supportive social network factors, self efficacy, and factors related to purpose and meaning in life, were protective against AUD relapse. Despite heterogeneity in different methods, measures, and sample characteristics, these findings may contribute to a better therapeutic understanding in which specific factors are associated with relapse and those that prevent relapse. Such factors may have a role in a personalized medicine framework to improve patient outcomes.