1
|
Raad M, Kim AH, Durand WM, Kebaish KM. Low bone mineral density: a primer for the spine surgeon. Spine Deform 2024:10.1007/s43390-024-00913-z. [PMID: 39060777 DOI: 10.1007/s43390-024-00913-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/01/2024] [Indexed: 07/28/2024]
Abstract
Within spinal surgery, low bone mineral density is associated with several postoperative complications, such as proximal junctional kyphosis, pseudoarthrosis, and screw loosening. Although modalities such as CT and MRI can be utilized to assess bone quality, DEXA scans, the "Gold Standard" for diagnosing osteoporosis, is not routinely included in preoperative workup. With an increasing prevalence of osteoporosis in an aging population, it is critical for spine surgeons to understand the importance of evaluating bone mineral density preoperatively to optimize postoperative outcomes. The purpose of this state-of-the-art review is to provide surgeons a summary of the evaluation, treatment, and implications of low bone mineral density in patients who are candidates for spine surgery.
Collapse
Affiliation(s)
- Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St. 5th Floor, Baltimore, MD, 21205, USA
| | - Andrew H Kim
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St. 5th Floor, Baltimore, MD, 21205, USA
| | - Wesley M Durand
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St. 5th Floor, Baltimore, MD, 21205, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St. 5th Floor, Baltimore, MD, 21205, USA.
| |
Collapse
|
2
|
FENG Y, LIU Y, DANG X, LIN Z, ZHANG Y, CHE Z, LI X, PAN X, LIU F, ZHENG P. Exploring the multicomponent synergy mechanism of Zuogui Wan on postmenopausal osteoporosis by a systems pharmacology strategy. J TRADIT CHIN MED 2024; 44:489-495. [PMID: 38767632 PMCID: PMC11077145 DOI: 10.19852/j.cnki.jtcm.20231204.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/14/2023] [Indexed: 05/22/2024]
Abstract
OBJECTIVE To explore the multi-component synergistic mechanism of Zuogui Wan (, ZGW) in treating postmenopausal osteoporosis (PMOP). METHODS The main components and target genes of ZGW were screened via the Traditional Chinese Medicine Systems Pharmacology (TCMSP). In addition, the target gene sets of PMOP were derived from the GeneCards and Online Mendelian Inheritance in Man databases. The search tool for recurring instances of neighbouring genes (STRING) 11.0 software was used to analyze the interaction among intersecting genes. Cytoscape 3.6.1 software and the Matthews correlation coefficient (MCC) algorithm were used to screen the core genes. Fifty Sprague-Dawley female rats were randomly divided into the sham-operated (Sham) group and the four ovariectomized (OVX) subgroups. Rats subjected to Sham or OVX were administered with the vehicle (OVX, 1 mL water/100 g weight), 17β-estradiol (E2, 50 μg·kg-1·d-1), and lyophilized powder of ZGW at a low dose of 2.3 (ZGW-L) and high dose of 4.6 (ZGW-H) g·kg-1·d-1 for three months. The bone density and bone strength were assessed using dual-energy X-ray and three-point bending tests, respectively. Furthermore, enzyme-linked immun-osorbent assay, Hematoxylin-eosin staining, and western blot analysis were used to determine the potential pharmacological mechanisms of action of ZGW in PMOP. RESULTS A total of 117 active compounds of ZGW were screened from the TCMSP. Furthermore, 108 intersecting genes of drugs and diseases were identified. Using STRING software and the MCC algorithm, ten core genes, including C-X-C chemokine living 8 (CXCL8), C-C chemokine receptor type 2 (CCR2), alpha-2a active receptor (ADRA2A), melatonin receptor type 1B (MTNR1B), and amyloid-beta A4 protein (APP), were identified. The anti-osteoporosis regulation network of ZGW was constructed using the Cytoscape software. The animal experiments demonstrated that ZGW groups significantly reduced the serum levels of β-C-terminal telopeptide of type I collagen (β-CTX) and increased serum levels of bone-specific alkaline phosphatase (BALP) (P < 0.05, P < 0.01). The OVX group exhibited a significant decrease in bone mineral density and bone strength compared with the Sham group (P < 0.01). Moreover, treatment with ZGW resulted in increased trabecular thickness, improved arrangement of trabecular structure, and reduced empty bone lacunae. Furthermore, treatment with ZGW significantly increased the protein expression of CXCL8, ADRA2A, and CCR2 (P < 0.05, P < 0.01), and significantly decreased the protein expression of Runx2 (P < 0.01). Furthermore, the ZGW and E2 groups demonstrated significantly increased BMD (P < 0.05, P < 0.01), improved bone strength (P < 0.05, P < 0.01), reduced expression of CXCL8, ADRA2A, and CCR2, and increased runt-related transcription factor 2 levels in bone tissue (P < 0.05, P < 0.01) compared with the OVX group. However, there were no significant differences in MTNR1B and APP expression among the groups. CONCLUSION ZGW shows synergistic mechanisms in PMOP through multiple components, targets, and pathways.
Collapse
Affiliation(s)
- Yanchen FENG
- 1 Traditional Chinese Medicine (Zhong Jing) School, Henan University of Chinese Medicine, Zhengzhou 450046, China
| | - Yali LIU
- 1 Traditional Chinese Medicine (Zhong Jing) School, Henan University of Chinese Medicine, Zhengzhou 450046, China
| | - Xue DANG
- 1 Traditional Chinese Medicine (Zhong Jing) School, Henan University of Chinese Medicine, Zhengzhou 450046, China
| | - Zixuan LIN
- 2 Hospital of Encephalopathy, the First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou 450000, China
| | - Yunke ZHANG
- 2 Hospital of Encephalopathy, the First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou 450000, China
| | - Zhiying CHE
- 1 Traditional Chinese Medicine (Zhong Jing) School, Henan University of Chinese Medicine, Zhengzhou 450046, China
| | - Xiang LI
- 3 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Research Units of Infectious Disease and Microecology, Chinese Academy of Medical Sciences, Hangzhou 31000, China
| | - Xiaolong PAN
- 1 Traditional Chinese Medicine (Zhong Jing) School, Henan University of Chinese Medicine, Zhengzhou 450046, China
| | - Feixiang LIU
- 2 Hospital of Encephalopathy, the First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou 450000, China
| | - Pan ZHENG
- 1 Traditional Chinese Medicine (Zhong Jing) School, Henan University of Chinese Medicine, Zhengzhou 450046, China
| |
Collapse
|
3
|
Tao ZS, Ma T, Yang M. Cyclosporine a inhibits bone regeneration and induces bone loss in a rat model. Int Immunopharmacol 2024; 132:111951. [PMID: 38552293 DOI: 10.1016/j.intimp.2024.111951] [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: 01/12/2024] [Revised: 03/13/2024] [Accepted: 03/26/2024] [Indexed: 05/01/2024]
Abstract
Cyclosporine A (CSA) is an immunosuppressant that has been extensively studied for its side effects on inhibiting osseointegration of titanium implants. However, the impact of CSA on bone healing in postmenopausal osteoporosis remains unknown. Therefore, this study aimed to investigate the effect of CSA on bone repair in an ovariectomized (OVX) rat model through both in vitro and in vivo experiments. We examined the interventions of CSA on osteoblast progenitor cells MC3T3-E1 and assessed their effects on biological function using RT-qPCR, CCK-8 assay, alizarin red staining, and alkaline phosphatase staining. Furthermore, we evaluated the effects of CSA on bone regeneration and bone mass in both OVX rat models and femoral diaphysis bone defect models. The results from the CCK-8 experiment indicated a positive influence of experimental doses of CSA on osteogenic differentiation of MC3T3-E1 cells. ALP expression levels and calcified nodules were also evaluated, suggesting that CSA intervention promoted osteogenic differentiation in MC3T3-E1 cells. Additionally, specific gene expressions including OPN, Runx-2, OC, and Col1a1 were up-regulated after CSA intervention. Biomechanical parameters aligned with histological analysis as well as micro-CT scans confirmed worse bone microstructure and strength following CSA intervention. Our findings preliminarily suggest that whether it is normal or osteoporotic bones, CSA has adverse effects on bone health which are associated with elevated-bone turnover.
Collapse
Affiliation(s)
- Zhou-Shan Tao
- Department of Orthopedics, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, No. 2, Zhe Shan Xi Road, Wuhu 241001, Anhui, PR China; Anhui Province Key Laboratory of Non-coding RNA Basic and Clinical Transformation, No. 2, Zhe Shan Xi Road, Wuhu 241001, Anhui, PR China.
| | - Tao Ma
- Department of Orthopedics, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, No. 2, Zhe Shan Xi Road, Wuhu 241001, Anhui, PR China
| | - Min Yang
- Department of Orthopedics, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, No. 2, Zhe Shan Xi Road, Wuhu 241001, Anhui, PR China
| |
Collapse
|
4
|
Pu A, Paul S, Luke B, Bhattacharyya T. Better Mobility Is Associated With Higher Incomes and Longer Working Years Among Older Adults. Clin Orthop Relat Res 2024; 482:9-19. [PMID: 37878467 PMCID: PMC10723861 DOI: 10.1097/corr.0000000000002886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 09/12/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Robust physical mobility is the key to healthy independent aging. Although the association between socioeconomic status and health is well documented, it is unclear whether there is a relationship between mobility and income, because income data are not readily available. QUESTIONS/PURPOSES (1) Do individuals with better mobility have higher incomes? (2) Does maintaining mobility over time allow individuals to keep working? (3) Is exercise associated with higher mobility over time? METHODS We obtained longitudinal income and health data from the nationally representative Health and Retirement Study. Three cohorts were used. First, we studied the relationship between household income and mobility (on a 6-point index of walking impairment) in 19,430 adults who were assessed in 2016 (representing 93% of the 20,805-person total cohort). We measured the association of mobility and household income in a multivariate linear regression analysis of age, gender, health conditions, and education. We then identified a second group of 1094 individuals with unrestricted mobility in the year 2000 and compared differences in income and working rates between those who maintained mobility and those who lost mobility after 10 years. Finally, we identified a third group of 7063 individuals who were 60 to 80 years old in 2012, divided the group by how often they engaged in exercise, and observed differences in mobility after 4 years. RESULTS After adjusting for covariates, a drop of one level of mobility was associated with a USD 3410 reduction in annual household income (95% CI USD 2890 to USD 3920; p < 0.001). After 10 years, individuals who maintained their mobility had incomes that were USD 6500 higher than that of individuals who were not working (95% CI USD 2300 to USD 10,300; p < 0.001) and were more likely to be working (40% versus 34.5%; p < 0.001). Exercising at least once per week was associated with better mobility 4 years later (mobility score 4.46 ± 0.08 versus 3.66 ± 0.08; p < 0.001). CONCLUSION Better mobility was associated with more than USD 3000 in annual income. Regular exercise and other interventions that improve mobility may have meaningful returns on investment. CLINICAL RELEVANCE Because greater mobility is strongly associated with higher income, orthopaedic interventions may be undervalued.
Collapse
Affiliation(s)
- Alex Pu
- Clinical Trials and Outcomes Branch, National Institute for Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Subrata Paul
- Integrated Data Sciences Section, Research Technologies Branch, NIADH/NIH, Bethesda, MD, USA
| | - Brian Luke
- Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Timothy Bhattacharyya
- Clinical Trials and Outcomes Branch, National Institute for Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
5
|
Tian L, Luo C, Li YF, Wang QY, Qu XL, Yue C, Xu LL, Yang YY, Sheng ZF. Economic evaluation of four treatment strategies for postmenopausal patients with osteoporosis and a recent fracture in mainland China: a cost-effectiveness analysis. Arch Osteoporos 2023; 18:100. [PMID: 37460858 DOI: 10.1007/s11657-023-01309-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 07/06/2023] [Indexed: 07/20/2023]
Abstract
Postmenopausal patients with osteoporosis who have a recent fracture are at very high risk of fracture, and this study finds that stratified treatment based on fracture risk would be a cost-effective treatment option for this population. PURPOSE To evaluate the cost-effectiveness of four anti-osteoporosis medications (denosumab, zoledronate, teriparatide, and alendronate) for postmenopausal osteoporotic women in mainland China, using a stratified treatment strategy recommended by the American Association of Clinical Endocrinologists and the American College of Endocrinology (AACE/ACE). METHODS A microsimulation Markov model was used to compare the cost-effectiveness of the four treatments in postmenopausal osteoporotic patients of different ages (65, 70, 75, and 80 years), with a recent fracture from the Chinese healthcare perspective. The primary outcome was the incremental cost-effectiveness ratio (ICER), which represent the incremental cost per quality-adjusted life-year (QALY) obtained. One-way deterministic sensitivity analysis (DSA) and probabilistic sensitivity analysis (PSA) were performed to assess the robustness of model findings. RESULTS Alendronate was dominated by denosumab-to-alendronate and zoledronate at all ages examined, indicating that the costs of the two drugs were lower, but QALYs was greater. However, teriparatide-to-alendronate yielded an ICER of $76,432.07/ QALY, compared with alendronate at age 65, which exceeded the pre-determined willingness-to-pay threshold of $37,653/ QALY. The results were similar at other ages. The DSA showed that the most sensitive parameters were drug efficacy for vertebral and wrist fractures, the relative risk of vertebral fractures, and the persistence of the drugs. The PSA showed that zoledronate had a 100% probability of being the most cost-effective treatment, with a willingness-to-pay threshold of $37,653/ QALY. CONCLUSION Stratified treatment based on very high fracture risk is more cost-effective than conventional pills in mainland China. Among the stratified treatments, zoledronate is the optimal option.
Collapse
Affiliation(s)
- Lin Tian
- Health Management Center, National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan, 410011, China
| | - Chuo Luo
- Health Management Center, National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan, 410011, China
| | - Yong-Fang Li
- Health Management Center, National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan, 410011, China
| | - Qin-Yi Wang
- Health Management Center, National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan, 410011, China
| | - Xiao-Li Qu
- Health Management Center, National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan, 410011, China
| | - Chun Yue
- Health Management Center, National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan, 410011, China
| | - Lu-Lu Xu
- Health Management Center, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yan-Yi Yang
- Health Management Center, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Zhi-Feng Sheng
- Health Management Center, National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan, 410011, China.
| |
Collapse
|
6
|
Hiligsmann M, Silverman SS, Singer AJ, Pearman L, Mathew J, Wang Y, Caminis J, Reginster JY. Cost-Effectiveness of Sequential Abaloparatide/Alendronate in Men at High Risk of Fractures in the United States. PHARMACOECONOMICS 2023; 41:819-830. [PMID: 37086385 DOI: 10.1007/s40273-023-01270-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Abaloparatide (ABL) significantly increases bone mineral density in men with osteoporosis similar to what was reported in postmenopausal women with osteoporosis. The cost effectiveness of sequential treatment with ABL followed by alendronate (ALN) in men at high fracture risk was compared to relevant alternative treatments. METHODS A Markov-based microsimulation model based on a lifetime US healthcare decision maker perspective was developed to evaluate the cost (expressed in US$2021) per quality-adjusted life-years (QALYs) gained of sequential ABL/ALN. Comparators were sequential treatment unbranded teriparatide (TPTD)/ALN, generic ALN monotherapy, and no treatment. Discount rates of 3% were used. Consistent with practice guidelines, patients received 18 months of ABL or TPTD followed by ALN for 5 years, or 5 years of ALN monotherapy. Analyses were conducted in high-risk men aged over 50 years defined as having a bone mineral density T-score ≤-2.5 and a recent fracture. Time-specific risk of subsequent fracture after a recent fracture, incremental costs up to 5 years following fractures, real-world medication adherence, and mostly US men-specific data were included in the model. One-way and probabilistic sensitivity analyses were conducted to assess the robustness of results. RESULTS Over the full age range, sequential ABL/ALN led to more QALYs for lower costs than sequential unbranded TPTD/ALN, while no treatment was dominated (more QALYs, lower costs) by ALN monotherapy. The costs per QALY gained of sequential ABL/ALN were lower than the US threshold of US$150,000 versus generic ALN monotherapy. The probabilities that sequential ABL/ALN was cost effective compared to ALN monotherapy were estimated at 51% in men aged 50 years and between 88 and 90% in those aged ≥ 60 years. CONCLUSIONS Sequential therapy using ABL/ALN may be cost effective compared with generic ALN monotherapy in US men aged ≥ 50 years at high fracture risk, especially in those aged ≥ 60 years. Unbranded TPTD/ALN and no treatment were dominated interventions (less QALY, more costs) compared with ABL/ALN or ALN monotherapy.
Collapse
Affiliation(s)
- Mickaël Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Stuart S Silverman
- Cedars-Sinai Medical Center, Los Angeles and the OMC Clinical Research Center, Beverly Hills, CA, USA
| | - Andrea J Singer
- MedStar Georgetown University Hospital and Georgetown University Medical Center, Washington, DC, USA
| | | | | | | | | | - Jean-Yves Reginster
- Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Chair for Biomarkers of Chronic Diseases, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| |
Collapse
|
7
|
Li N, Beaudart C, Cauley JA, Ing SW, Lane NE, Reginster JY, Silverman S, Singer AJ, Hiligsmann M. Cost Effectiveness Analyses of Interventions for Osteoporosis in Men: A Systematic Literature Review. PHARMACOECONOMICS 2023; 41:363-391. [PMID: 36738425 PMCID: PMC10020287 DOI: 10.1007/s40273-022-01239-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 05/06/2023]
Abstract
BACKGROUND Osteoporosis is often considered to be a disease of women. Over the last few years, owing to the increasing clinical and economic burden, the awareness and imperative for identifying and managing osteoporosis in men have increased substantially. With the approval of agents to treat men with osteoporosis, more economic evaluations have been conducted to assess the potential economic benefits of these interventions. Despite this concern, there is no specific overview of cost-effectiveness analyses for the treatment of osteoporosis in men. OBJECTIVES This study aims (1) to systematically review economic evaluations of interventions for osteoporosis in men; (2) to critically appraise the quality of included studies and the source of model input data; and (3) to investigate the comparability of results for studies including both men and women. METHODS A literature search mainly using MEDLINE (via Ovid) and Embase databases was undertaken to identify original articles published between 1 January, 2000 and 30 June, 2022. Studies that assessed the cost effectiveness of interventions for osteoporosis in men were included. The Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases and the International Osteoporosis Foundation osteoporosis-specific guideline was used to assess the quality of design, conduct, and reporting of included studies. RESULTS Of 2973 articles identified, 25 studies fulfilled the inclusion criteria, classified into economic evaluations of active drugs (n = 8) or nutritional supplements (n = 4), intervention thresholds (n = 5), screening strategies (n = 6), and post-fracture care programs (n = 2). Most studies were conducted in European countries (n = 15), followed by North America (n = 9). Bisphosphonates (namely alendronate) and nutritional supplements were shown to be generally cost effective compared with no treatment in men over 60 years of age with osteoporosis or prior fractures. Two other studies suggested that denosumab was cost effective in men aged 75 years and older with osteoporosis compared with bisphosphates and teriparatide. Intervention thresholds at which bisphosphonates were found to be cost effective varied among studies with a 10-year probability of a major osteoporotic fracture that ranged from 8.9 to 34.2% for different age categories. A few studies suggested cost effectiveness of screening strategies and post-fracture care programs in men. Similar findings regarding the cost effectiveness of drugs and intervention thresholds in women and men were captured, with slightly greater incremental cost-effectiveness ratios in men. The quality of the studies included had an average score of 18.8 out of 25 (range 13-23.5). Hip fracture incidence and mortality risk were mainly derived from studies in men, while fracture cost, treatment efficacy, and disutility were commonly derived from studies in women or studies combining both sexes. CONCLUSIONS Anti-osteoporosis drugs and nutritional supplements are generally cost effective in men with osteoporosis. Screening strategies and post-fracture care programs also showed economic benefits for men. Cost-effectiveness and intervention thresholds were generally similar in studies conducted in both men and women, with slightly greater incremental cost-effectiveness ratios in men.
Collapse
Affiliation(s)
- Nannan Li
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Charlotte Beaudart
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands
- WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liège, Belgium
| | - Jane A Cauley
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven W Ing
- Division of Endocrinology, Diabetes and Metabolism, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Nancy E Lane
- Department of Medicine, University of California at Davis, School of Medicine, Sacramento, CA, USA
| | - Jean-Yves Reginster
- WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liège, Belgium
- Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - Stuart Silverman
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Andrea J Singer
- Departments of Obstetrics and Gynecology and Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Mickaël Hiligsmann
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands.
| |
Collapse
|
8
|
Hong P, Liu R, Rai S, Liu J, Zhou Y, Zheng Y, Li J. Is abaloparatide more efficacious on increasing bone mineral density than teriparatide for women with postmenopausal osteoporosis? An updated meta-analysis. J Orthop Surg Res 2023; 18:116. [PMID: 36797767 PMCID: PMC9936648 DOI: 10.1186/s13018-023-03595-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 02/08/2023] [Indexed: 02/18/2023] Open
Abstract
PURPOSE Osteoporosis poses a challenge to public health, causing fragility fractures, especially in postmenopausal women. Abaloparatide (ABL) is an effective anabolic agent to improve bone formation and resorption among postmenopausal women with osteoporosis. Our meta-analysis aims to assess the effectiveness and safety of ABL versus teriparatide (TPTD) in improving bone mineral density (BMD). METHODS We searched Medline, Embase, Web of Science, Cochrane databases and Clinicaltrial.gov until September 2, 2022. We included data from randomized controlled trials (RCTs) and post hoc analyses of RCTs. Outcomes included BMD change from baseline and risks of adverse events. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool was used to evaluate the quality of outcomes. RESULTS Four studies including 16 subgroups were included in this study. In particular, RCTs with head-to-head comparisons of ABL and TPTD were used in the meta-analysis, and all were from manufacturer-sponsored trials. All parameters in 24 weeks except lumbar spine (versus TPTD) showed significant advantages in the ABL group. Only the results of two subgroups in ABL versus TPTD demonstrated High GRADE quality (femoral neck: weighted mean difference (WMD) = 1.58 [0.52, 2.63]; Total hip: WMD = 1.46 [0.59, 2.32]). However, our fracture data were insufficient. Besides, we found no evident difference in serious adverse events or deaths in either group and the incidence of hypercalcemia in the ABL group lessened by 51% compared with the TPTD group. Nevertheless, compared with placebo, ABL demonstrated higher risks of nausea and palpitations. CONCLUSION ABL demonstrated a beneficial effect on BMD compared to both placebo and TPTD for postmenopausal women with osteoporosis. ABL also had insignificantly lowered adverse event risk than TPTD. ABL is an alternative for patients with postmenopausal osteoporosis.
Collapse
Affiliation(s)
- Pan Hong
- grid.33199.310000 0004 0368 7223Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China
| | - Ruikang Liu
- grid.33199.310000 0004 0368 7223Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Department of Orthopaedics and Trauma Surgery, Dubai Investment Park Br, Karama Medical Center, Dubai, United Arab Emirates
| | - JiaJia Liu
- grid.33199.310000 0004 0368 7223First Clinical School, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - YeMing Zhou
- grid.33199.310000 0004 0368 7223Basic Medical School, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China
| | - Yu Zheng
- Basic Medical School, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Jin Li
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| |
Collapse
|
9
|
Qaseem A, Hicks LA, Etxeandia-Ikobaltzeta I, Shamliyan T, Cooney TG, Cross JT, Fitterman N, Lin JS, Maroto M, Obley AJ, Tice JA, Tufte JE. Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians. Ann Intern Med 2023; 176:224-238. [PMID: 36592456 PMCID: PMC10885682 DOI: 10.7326/m22-1034] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
DESCRIPTION This guideline updates the 2017 American College of Physicians (ACP) recommendations on pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults. METHODS The ACP Clinical Guidelines Committee based these recommendations on an updated systematic review of evidence and graded them using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. AUDIENCE AND PATIENT POPULATION The audience for this guideline includes all clinicians. The patient population includes adults with primary osteoporosis or low bone mass. RECOMMENDATION 1A ACP recommends that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in postmenopausal females diagnosed with primary osteoporosis (strong recommendation; high-certainty evidence). RECOMMENDATION 1B ACP suggests that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis (conditional recommendation; low-certainty evidence). RECOMMENDATION 2A ACP suggests that clinicians use the RANK ligand inhibitor (denosumab) as a second-line pharmacologic treatment to reduce the risk of fractures in postmenopausal females diagnosed with primary osteoporosis who have contraindications to or experience adverse effects of bisphosphonates (conditional recommendation; moderate-certainty evidence). RECOMMENDATION 2B ACP suggests that clinicians use the RANK ligand inhibitor (denosumab) as a second-line pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis who have contraindications to or experience adverse effects of bisphosphonates (conditional recommendation; low-certainty evidence). RECOMMENDATION 3 ACP suggests that clinicians use the sclerostin inhibitor (romosozumab, moderate-certainty evidence) or recombinant PTH (teriparatide, low-certainty evidence), followed by a bisphosphonate, to reduce the risk of fractures only in females with primary osteoporosis with very high risk of fracture (conditional recommendation). RECOMMENDATION 4 ACP suggests that clinicians take an individualized approach regarding whether to start pharmacologic treatment with a bisphosphonate in females over the age of 65 with low bone mass (osteopenia) to reduce the risk of fractures (conditional recommendation; low-certainty evidence).
Collapse
Affiliation(s)
- Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania (A.Q., I.E., T.S.)
| | - Lauri A Hicks
- Centers for Disease Control and Prevention, Atlanta, Georgia (L.A.H.)
| | | | - Tatyana Shamliyan
- American College of Physicians, Philadelphia, Pennsylvania (A.Q., I.E., T.S.)
| | - Thomas G Cooney
- Oregon Health & Science University, Portland, Oregon (T.G.C.)
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Luo C, Qin SX, Wang QY, Li YF, Qu XL, Yue C, Hu L, Sheng ZF, Wang XB, Wan XM. Cost-effectiveness analysis of five drugs for treating postmenopausal women in the United States with osteoporosis and a very high fracture risk. J Endocrinol Invest 2023; 46:367-379. [PMID: 36044169 PMCID: PMC9428883 DOI: 10.1007/s40618-022-01910-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/20/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Five strategies were recommended by the American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) guidelines for the treatment of postmenopausal osteoporosis (PMO) patients with a very high fracture risk. We aimed to assess their cost-effectiveness in the United States (US). METHODS A microsimulation Markov model was created to compare the cost-effectiveness of five treatment strategies, including zoledronate, denosumab, abaloparatide, teriparatide, and romosozumab in PMO patients with a recent fracture from the healthcare perspective of the US. The data used in the model were obtained from published studies or online resources. Base-case analysis, one-way deterministic sensitivity analysis (DSA) and probability sensitivity analysis (PSA) were conducted for 65-, 70-, 75-, and 80-year-old patients. RESULTS In base case, at 65 years, zoledronate was the cheapest strategy. The incremental cost-effectiveness ratios (ICER, which represent incremental costs per QALY gained) of denosumab, teriparatide, abaloparatide, and romosozumab against zoledronate were $13,020/QALY (quality-adjusted years), $477,331 /QALY, $176,287/QALY, and $98,953/QALY, respectively. Under a willing-to-pay (WTP, which means the highest price a consumer will pay for one unit of a good of service) threshold of $150,000/QALY, denosumab and romosozumab were cost-effective against zoledronate. The PSA results showed that denosumab was the most cost-effective option with WTP thresholds of $50,000/QALY, $100,000/QALY and $150,000/QALY. The results were similar in other age groups. The DSA results indicated that the most common parameters that have important influence on the outcome were drug persistence, incidence of adverse events, the efficacy of drugs on hip fractures and the cost of the drug. CONCLUSION AND RELEVANCE Among PMO patients with a very high fracture risk in the US, zoledronate is the cheapest strategy and denosumab is the most cost-effective choice among these five strategies.
Collapse
Affiliation(s)
- C Luo
- Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, Health Management Center, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Changsha, 410011, Hunan, People's Republic of China
| | - S-X Qin
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, 139 Renmin Middle Road, Changsha, 410011, Hunan, People's Republic of China
| | - Q-Y Wang
- Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, Health Management Center, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Changsha, 410011, Hunan, People's Republic of China
| | - Y-F Li
- Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, Health Management Center, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Changsha, 410011, Hunan, People's Republic of China
| | - X-L Qu
- Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, Health Management Center, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Changsha, 410011, Hunan, People's Republic of China
| | - C Yue
- Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, Health Management Center, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Changsha, 410011, Hunan, People's Republic of China
| | - L Hu
- Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, Health Management Center, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Changsha, 410011, Hunan, People's Republic of China
| | - Z-F Sheng
- Hunan Provincial Key Laboratory of Metabolic Bone Diseases, Department of Metabolism and Endocrinology, Health Management Center, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Changsha, 410011, Hunan, People's Republic of China.
| | - X-B Wang
- Divisions of Endocrinology, Metabolism, and Nutrition, Departments of Medicine and Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - X-M Wan
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, 139 Renmin Middle Road, Changsha, 410011, Hunan, People's Republic of China.
| |
Collapse
|
11
|
Yu G, Tong S, Liu J, Wan Y, Wan M, Li S, You R. A systematic review of cost‑effectiveness analyses of sequential treatment for osteoporosis. Osteoporos Int 2022; 34:641-658. [PMID: 36527476 DOI: 10.1007/s00198-022-06626-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022]
Abstract
Sequential treatment of osteoporosis has been increasingly mentioned in recent years. However, the corresponding systematic review has not been reported. This study aims to systematically review and assess all full-text pharmacoeconomic studies of sequential treatment for osteoporosis. A comprehensive literature search was performed using PubMed, EMBASE (Ovid), CNKI, and Wanfang Database to identify original articles, published before June 17, 2022. The quality of included articles was evaluated by the updated Consolidated Health Economic Evaluation Reporting Standards (CHEERS 2022) and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases International Osteoporosis Foundation (ESCEO-IOF). In general, ten articles were included in this review. For the comparison between sequential treatment and bisphosphonate monotherapy, more than 75% of studies demonstrated the sequential treatment was cost-effective or dominant, with the exception of sequential treatment involving teriparatide. When the comparisons occurred between the two sequential treatment groups, the sequential treatments associated with either abaloparatide or romosozumab were cost-effective or dominant compared to the sequential treatment involving teriparatide. Several major key drivers of cost-effectiveness included drug cost, medication persistence and adherence, drug effect on fracture risk, offset effect, time horizon, and baseline fracture risk. The most of studies were identified as high quality in CHEERS (2022) and ESCEO-IOF. The cost-effectiveness of sequential treatment for osteoporosis is influenced by multiple factors. Generally, the sequential treatments involving abaloparatide, romosozumab, denosumab, and bisphosphonates may be considered as the preferred option for osteoporosis with high fracture risk, while the sequential treatment with teriparatide was not a cost-effectiveness strategy. The ESCEO-IOF and CHEER (2022) increase the transparency, comparability, extrapolation, and quality of research, engage patients and the general public in research on health services and policies, and help improve the quality of health technology assessment.
Collapse
Affiliation(s)
- Guangyi Yu
- Department of Pharmacy, People's Hospital of Dongxihu District, Wuhan, Hubei, China
| | - Suiju Tong
- Department of Pharmacy, People's Hospital of Dongxihu District, Wuhan, Hubei, China
| | - Jinyu Liu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yuansheng Wan
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei, China
| | - Min Wan
- Department of Pharmacy, People's Hospital of Dongxihu District, Wuhan, Hubei, China
| | - Sujuan Li
- Department of Pharmacy, People's Hospital of Dongxihu District, Wuhan, Hubei, China
| | - Ruxu You
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei, China.
| |
Collapse
|
12
|
Osteoporosis. Orthop Nurs 2022; 41:428-433. [DOI: 10.1097/nor.0000000000000899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
13
|
Curtis EM, Reginster JY, Al-Daghri N, Biver E, Brandi ML, Cavalier E, Hadji P, Halbout P, Harvey NC, Hiligsmann M, Javaid MK, Kanis JA, Kaufman JM, Lamy O, Matijevic R, Perez AD, Radermecker RP, Rosa MM, Thomas T, Thomasius F, Vlaskovska M, Rizzoli R, Cooper C. Management of patients at very high risk of osteoporotic fractures through sequential treatments. Aging Clin Exp Res 2022; 34:695-714. [PMID: 35332506 PMCID: PMC9076733 DOI: 10.1007/s40520-022-02100-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/18/2022] [Indexed: 12/11/2022]
Abstract
Osteoporosis care has evolved markedly over the last 50 years, such that there are now an established clinical definition, validated methods of fracture risk assessment and a range of effective pharmacological agents. Currently, bone-forming (anabolic) agents, in many countries, are used in those patients who have continued to lose bone mineral density (BMD), patients with multiple subsequent fractures or those who have fractured despite treatment with antiresorptive agents. However, head-to-head data suggest that anabolic agents have greater rapidity and efficacy for fracture risk reduction than do antiresorptive therapies. The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) convened an expert working group to discuss the tools available to identify patients at high risk of fracture, review the evidence for the use of anabolic agents as the initial intervention in patients at highest risk of fracture and consider the sequence of therapy following their use. This position paper sets out the findings of the group and the consequent recommendations. The key conclusion is that the current evidence base supports an "anabolic first" approach in patients found to be at very high risk of fracture, followed by maintenance therapy using an antiresorptive agent, and with the subsequent need for antiosteoporosis therapy addressed over a lifetime horizon.
Collapse
Affiliation(s)
- Elizabeth M Curtis
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - Jean-Yves Reginster
- WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liège, Belgium
- Department of Public Health, Epidemiology and Health Economics, University of Liège, CHU Sart Tilman B23, 4000, Liège, Belgium
| | - Nasser Al-Daghri
- Biochemistry Department, College of Science, King Saud University, 11451, Riyadh, Kingdom of Saudi Arabia
| | - Emmanuel Biver
- Division of Bone Diseases, Department of Medicine, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Maria Luisa Brandi
- F.I.R.M.O, Italian Foundation for the Research on Bone Diseases, Florence, Italy
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liege, CHU de Liège, Liège, Belgium
| | - Peyman Hadji
- Center of Bone Health, Frankfurt, Germany
- Philipps-University of Marburg, Marburg, Germany
| | | | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mickaël Hiligsmann
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | | | - John A Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
| | - Jean-Marc Kaufman
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - Olivier Lamy
- University of Lausanne, UNIL, CHUV, Lausanne, Switzerland
| | - Radmila Matijevic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
- Clinical Center of Vojvodina, Clinic for Orthopedic Surgery, Novi Sad, Serbia
| | - Adolfo Diez Perez
- Department of Internal Medicine, Hospital del Mar-IMIM, Autonomous University of Barcelona and CIBERFES, Instituto Carlos III, Madrid, Spain
| | - Régis Pierre Radermecker
- Department of Diabetes, Nutrition and Metabolic Disorders, Clinical Pharmacology, University of Liege, CHU de Liège, Liège, Belgium
| | | | - Thierry Thomas
- Department of Rheumatology, Hôpital Nord, CHU Saint-Etienne, Saint-Etienne, France
- INSERM U1059, Université de Lyon, Université Jean Monnet, Saint-Etienne, France
| | | | - Mila Vlaskovska
- Medical Faculty, Department of Pharmacology and Toxicology, Medical University Sofia, Sofia, Bulgaria
| | - René Rizzoli
- Division of Bone Diseases, Department of Medicine, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK.
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK.
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
| |
Collapse
|
14
|
Söreskog E, Borgström F, Lindberg I, Ström O, Willems D, Libanati C, Kanis JA, Stollenwerk B, Charokopou M. A novel economic framework to assess the cost-effectiveness of bone-forming agents in the prevention of fractures in patients with osteoporosis. Osteoporos Int 2021; 32:1301-1311. [PMID: 33411005 PMCID: PMC8192365 DOI: 10.1007/s00198-020-05765-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/25/2020] [Indexed: 01/09/2023]
Abstract
UNLABELLED A novel cost-effectiveness model framework was developed to incorporate the elevated fracture risk associated with a recent fracture and to allow sequential osteoporosis therapies to be evaluated. Treating patients with severe osteoporosis after a recent fracture with a bone-forming agent followed by antiresorptive therapy can be cost-effective compared with antiresorptive therapy alone. Incorporating these novel technical attributes in economic evaluations can support appropriate policy and reimbursement decision-making. PURPOSE To develop a cost-effectiveness model accommodating increased fracture risk after a recent fracture and treatment sequencing. METHODS A micro-simulation cost-utility model was developed to accommodate both treatment sequencing and increased risk with recent fracture. The risk of fracture was estimated and simulated using the FRAX® algorithms combined with Swedish registry data on imminent fracture relative risk. In the base-case cost-effectiveness analysis, a sequential treatment starting with a bone-forming agent for 12 months followed by an antiresorptive agent for 48 months initiated immediately after a major osteoporotic fracture (MOF) in a 70-year-old woman with a T-score of 2.5 or less was compared to an antiresorptive treatment alone for 60 months. The model was populated with data relevant for a UK population reflecting a personal social service perspective. RESULTS The cost per additional quality-adjusted life year (QALY) gained in the base-case setting was estimated at £34,584. Sensitivity analyses revealed the sequential treatment to be cost-saving compared with administering a bone-forming treatment alone. Without simulating an elevated fracture risk immediately after a recent fracture, the cost per QALY changed from £34,584 to £62,184. CONCLUSION Incorporating imminent fracture risk in economic evaluations has a significant impact on the cost-effectiveness when evaluating fracture prevention treatments in patients with osteoporosis who sustained a recent fracture. Bone-forming treatment followed by antiresorptive therapy can be cost-effective compared to antiresorptive therapy alone depending on treatment acquisition costs.
Collapse
Affiliation(s)
| | - F Borgström
- Quantify Research, Stockholm, Sweden.
- Karolinska Institutet, Stockholm, Sweden.
| | | | - O Ström
- Quantify Research, Stockholm, Sweden
- Karolinska Institutet, Stockholm, Sweden
| | | | | | - J A Kanis
- University of Sheffield, Sheffield, UK
- Mary McKillop Institute for Heath Research, Australian Catholic University, Melbourne, Australia
| | | | | |
Collapse
|
15
|
Gupta A, Cha T, Schwab J, Fogel H, Tobert DG, Razi AE, Paulino C, Hecht AC, Bono CM, Hershman S. Osteoporosis is under recognized and undertreated in adult spinal deformity patients. JOURNAL OF SPINE SURGERY 2021; 7:1-7. [PMID: 33834122 DOI: 10.21037/jss-20-668] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Adult spinal deformity (ASD) patients may have osteoporosis, predisposing them to an increased risk for surgical complications. Prior studies have demonstrated that treating osteoporosis improves surgical outcomes. In this study we determine the prevalence of osteoporosis in ASD patients undergoing long spinal fusions and the rate at which osteoporosis is treated. Methods ASD patients who frequented either of two major academic medical centers from 2010 through 2019 were studied. All study participants were at least 40 years of age and endured a spinal fusion of at least seven vertebral levels. Medical records were explored for a diagnosis of osteoporosis via ICD-10 code and, if present, whether pharmacological treatment was prescribed. T-tests and chi-squared analyses were used to determine statistical significance. Results Three hundred ninety-nine patients matched the study's inclusion criteria. Among this group, 131 patients (32.8%) had been diagnosed with osteoporosis prior to surgery. With a mean age of 66.4 years, osteoporotic patients were on average three years older than non-osteoporotic (P=0.002) and more likely to be female (74.8% vs. 61.9%; P=0.01). At the time of surgery, 34.4% of osteoporotic patients were receiving pharmacological treatment. Although not statistically significant, women were more likely to receive medical treatment than men (P=0.07). Conclusions The prevalence of osteoporosis in ASD patients undergoing a long spinal fusion is substantially higher than that of the general population. Surgeons should have a low threshold for bone density testing in ASD patients. With only about one-third of osteoporotic patients treated, there is a classic "missed opportunity" in this population.
Collapse
Affiliation(s)
- Anmol Gupta
- Department of Orthopaedics, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Cha
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph Schwab
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Harold Fogel
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel G Tobert
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Afshin E Razi
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Maimonides Bone and Joint Center, Maimonides Medical Center, Brooklyn, NY, USA
| | - Carl Paulino
- Department of Orthopaedic Surgery, Fe Health Sciences University, New York-Presbyterian (NYP) Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Andrew C Hecht
- Department of Orthopaedics, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher M Bono
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stuart Hershman
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
16
|
Li N, Cornelissen D, Silverman S, Pinto D, Si L, Kremer I, Bours S, de Bot R, Boonen A, Evers S, van den Bergh J, Reginster JY, Hiligsmann M. An Updated Systematic Review of Cost-Effectiveness Analyses of Drugs for Osteoporosis. PHARMACOECONOMICS 2021; 39:181-209. [PMID: 33026634 PMCID: PMC7867562 DOI: 10.1007/s40273-020-00965-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/19/2020] [Indexed: 05/23/2023]
Abstract
BACKGROUND Considering the heavy economic burden of osteoporotic fractures, the limits of healthcare resources, and the recent availability of new anti-osteoporosis drugs, there is continuing interest in economic evaluation studies of osteoporosis management strategies. OBJECTIVES This study aims to (1) systematically review recent economic evaluations of drugs for osteoporosis and (2) to apply an osteoporosis-specific guideline to critically appraise them. METHODS A literature search was undertaken using PubMed, EMBASE, National Health Service Economic Evaluation database, and the Cost-Effectiveness Analysis Registry to identify original articles containing economic evaluations of anti-osteoporosis drugs, published between 1 July, 2013 and 31 December, 2019. A recent European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases-International Osteoporosis Foundation (ESCEO-IOF) guideline for the conduct and reporting of economic evaluations in osteoporosis was used to assess the quality of included articles. RESULTS The database search retrieved 3860 records, of which 27 studies fulfilled the inclusion criteria. These studies were conducted in 15 countries; 12 active drugs were assessed, including various traditional pharmacological treatments such as bisphosphonates, raloxifene, strontium ranelate, denosumab, and teriparatide, and new agents such as abaloparatide, romosozumab, and gastro-resistant risedronate. Eight out of 12 studies that compared traditional oral bisphosphonates to other active interventions (denosumab, zoledronic acid, gastro-resistant risedronate, and teriparatide) suggested that the other active agents were generally cost-effective or dominant. Additionally, the cost-effectiveness of sequential therapy has recently been assessed and indications are that it can lead to extra health benefits (larger gains in quality-adjusted life-year). The key drivers of cost effectiveness included baseline fracture risk, drug effect on the risk of fractures, drug cost, and medication adherence/persistence. The current average score for quality assessment was 17 out of 25 (range 2-15); room for improvement was observed for most studies, which could potentially be explained by the fact that most studies were published prior to the osteoporosis-specific guideline. Greater adherence to guideline recommendations was expected for future studies. The quality of reporting was also suboptimal, especially with regard to treatment side effects, treatment effect after discontinuation, and medication adherence. CONCLUSIONS This updated review provides an overview of recently published cost-effectiveness analyses. In comparison with a previous review, recent economic evaluations of anti-osteoporosis drugs were conducted in more countries and included more active drugs and sequential therapy as interventions/comparators. The updated economic evidence could help decision makers prioritize health interventions and the unmet/unreported quality issues indicated by the osteoporosis-specific guideline could be useful in improving the transparency, quality, and comparability of future economic evaluations in osteoporosis.
Collapse
Affiliation(s)
- Nannan Li
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Dennis Cornelissen
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Stuart Silverman
- Cedars-Sinai Medical Center, UCLA School of Medicine and the OMC Clinical Research Center, Beverly Hills, CA, USA
| | - Daniel Pinto
- Department of Physical Therapy, Marquette University, Milwaukee, WI, USA
| | - Lei Si
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
- School of Health Policy & Management, Nanjing Medical University, Nanjing, China
| | - Ingrid Kremer
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Sandrine Bours
- Department of Internal Medicine, Subdivision of Rheumatology, Maastricht University Medical Centre, and CAPHRI Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Robin de Bot
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
- Department of Orthopedics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Annelies Boonen
- Department of Internal Medicine, Subdivision of Rheumatology, Maastricht University Medical Centre, and CAPHRI Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Silvia Evers
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Joop van den Bergh
- Department of Internal Medicine, VieCuri, Medical Centre, Venlo, The Netherlands
- Department of Internal Medicine, NUTRIM, Maastricht University Medical Centre, Maastricht, The Netherlands
- Faculty of Medicine, University Hasselt, Hasselt, Belgium
| | - Jean-Yves Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - Mickaël Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| |
Collapse
|
17
|
Aditya S, Rattan A. Sclerostin inhibition: A novel target for the treatment of postmenopausal osteoporosis. J Midlife Health 2021; 12:267-275. [PMID: 35264832 PMCID: PMC8849148 DOI: 10.4103/jmh.jmh_106_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 01/15/2021] [Accepted: 12/11/2021] [Indexed: 11/29/2022] Open
Abstract
Osteoporosis, a widespread skeletal disorder with a substantial economic load, is characterized by increased porosity of the bones resulting in vulnerability to fractures. When activated, the canonical Wnt signaling pathway results in osteoblastogenesis and bone formation. A Wnt ligand forms a complex with low-density lipoprotein receptor-related proteins 5 and 6 (Lrp5/6) and stimulates intracellular signaling cascades, leading to nuclear translocation of β-catenin and transcription of downstream molecules involved in osteoblast differentiation, maturation, and survival. Sclerostin (SOST), a glycoprotein produced by osteocytes, is an extracellular Wnt antagonist that blocks the binding of Wnt ligands to Lrp5/6, preventing the activation of the pathway and osteoblast-mediated bone formation subsequently. Inhibition of SOST represents a new therapeutic paradigm for the treatment of osteoporosis. Monoclonal antibodies to SOST include romosozumab, blosozumab, and setrusumab. With its unique dual effect of increasing bone formation (anabolic action) and decreasing bone resorption, the Food and Drug Administration approved romosozumab, a promising new treatment for postmenopausal osteoporosis. Its efficacy and safety have been established in trials. However, patients at high risk of cardiovascular or cerebrovascular events should not be prescribed romosozumab.
Collapse
|
18
|
Mori T, Crandall CJ, Fujii T, Ganz DA. Cost-effectiveness of sequential daily teriparatide/weekly alendronate compared with alendronate monotherapy for older osteoporotic women with prior vertebral fracture in Japan. Arch Osteoporos 2021; 16:72. [PMID: 33866457 PMCID: PMC8053143 DOI: 10.1007/s11657-021-00891-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/06/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED Using a Markov microsimulation model among hypothetical cohorts of community-dwelling older osteoporotic Japanese women with prior vertebral fracture over a lifetime horizon, we found that daily subcutaneous teriparatide for 2 years followed by weekly oral alendronate for 8 years was not cost-effective compared with alendronate monotherapy for 10 years. PURPOSE Teriparatide has proven efficacy in reducing osteoporotic fractures, but with substantial cost. We examined the cost-effectiveness of sequential teriparatide/alendronate (i.e., daily subcutaneous teriparatide for 2 years followed by weekly oral alendronate for 8 years) compared with alendronate monotherapy for 10 years among community-dwelling older osteoporotic women with prior clinical or morphometric vertebral fracture in Japan. METHODS Using a previously validated and updated Markov microsimulation model, we obtained incremental cost-effectiveness ratios (Japanese yen [¥] (or US dollars [$]) per quality-adjusted life year [QALY]) from the perspective of a single payer responsible for both public healthcare and long-term care. We assumed a lifetime horizon with a willingness-to-pay of ¥5million (or $47,500) per QALY in the base case. We modeled the cost of biosimilar teriparatide, which has been available since November 2019 in Japan, assuming the efficacy was the same as that of the brand version. RESULTS In the base case, sequential teriparatide/alendronate was not cost-effective compared with alendronate monotherapy. In deterministic sensitivity analyses, sequential teriparatide/alendronate would become cost-effective with 85%, 50%, and 15% price discounts to teriparatide at ages 70, 75, and 80, respectively, compared to the current biosimilar cost. Otherwise, results were especially sensitive to changes that affected efficacy of teriparatide or alendronate. In probabilistic sensitivity analyses, the probabilities of sequential teriparatide/alendronate being cost-effective were 0%, 1%, and 37% at ages 70, 75, and 80, respectively. CONCLUSIONS Among high-risk osteoporotic women in Japan, sequential teriparatide/alendronate was not cost-effective compared with alendronate monotherapy, even with the availability of biosimilar teriparatide.
Collapse
Affiliation(s)
- Takahiro Mori
- grid.20515.330000 0001 2369 4728Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki Japan ,grid.20515.330000 0001 2369 4728Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki Japan ,Department of General Internal Medicine, Eastern Chiba Medical Center, Togane, Chiba Japan
| | - Carolyn J. Crandall
- grid.19006.3e0000 0000 9632 6718Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA USA
| | - Tomoko Fujii
- grid.412708.80000 0004 1764 7572Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical & Research Center, The University of Tokyo Hospital, Tokyo, Japan
| | - David A. Ganz
- grid.417119.b0000 0001 0384 5381Geriatric Research, Education and Clinical Center and HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA USA ,grid.19006.3e0000 0000 9632 6718Division of Geriatrics, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA USA ,grid.34474.300000 0004 0370 7685Health Unit, RAND Corporation, Santa Monica, CA USA
| |
Collapse
|
19
|
Le QA, Kang JH, Lee S, Delevry D. Cost-Effectiveness of Treatment Strategies with Biologics in Accordance with Treatment Guidelines for Ankylosing Spondylitis: A Patient-Level Model. J Manag Care Spec Pharm 2020; 26:1219-1231. [PMID: 32996395 PMCID: PMC10391255 DOI: 10.18553/jmcp.2020.26.10.1219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Ankylosing spondylitis (AS) is a form of rheumatic disease caused by chronic inflammation of the axial skeleton. Patients with AS experience significant functional limitations and reduced quality of life. Consequently, AS imposes a substantial economic burden on society due to productivity loss and work disability. Biologics, including tumor necrosis factor (TNF) inhibitors and human anti-interleukin-17A monoclonal antibody (IL-17A) agents, are effective treatment strategies in relieving symptoms and slowing down disease progression. Currently, 5 TNF inhibitors and 2 IL-17A antibody agents are approved by the FDA for the management of AS. Of these agents, there is no clear preferred agent in initial biologic therapy, although an IL-17A antibody agent or alternative TNF inhibitor agent is recommended after failure of the initial TNF inhibitor therapy. OBJECTIVE To assess cost-effectiveness of treatment strategies with biologics, TNF inhibitor or IL-17A, in accordance with the treatment guidelines for patients with AS. METHODS An economic patient-level simulation combining decision-tree and Markov models was constructed from the U.S. health care payer's perspective over a 10-year time horizon. The current model examined 5 treatment strategies: (1) conventional care treatment with nonsteroidal anti-inflammatory drugs, (2) 1 TNF inhibitor, (3) an IL-17A antibody agent, (4) sequential therapy with 2 TNF inhibitors, and (5) sequential therapy with a TNF inhibitor followed by an IL-17A antibody agent. Initially, treatment responses were determined after 12-week treatments. Patients who responded to treatment entered a "responders" Markov model. Patients entered a "nonresponders" Markov model if they inadequately responded to treatment. In sequential treatment strategies, patients who inadequately responded to treatment with the first TNF inhibitor received a second TNF inhibitor or an IL-17A antibody agent. Health utility was estimated based on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Functional Index (BASFI) scores. The models accounted for real-world adherence to TNF inhibitor treatment. Scenario and probabilistic sensitivity analyses were performed to test the robustness and uncertainty of the model results. RESULTS Over a 10-year time horizon and 100,000 simulated patients for each treatment strategy, base-case results produced average total discounted per-patient costs of $19,765, $130,302, $159,934, $190,553, and $179,118 and quality-adjusted life-years (QALYs) of 4.675, 5.410, 5.499, 5.919, and 5.893 for conventional care, treatment strategies with 1 TNF inhibitor, an IL-17A, 2 TNF inhibitors, and a TNF inhibitor followed by an IL-17A, respectively. The optimal treatments at willingness-to-pay (WTP) thresholds ≤ $130,813 per QALY, between $130,813 per QALY and $442,728 per QALY, and > $442,728 per QALY were conventional care and sequential treatment strategies with 1 TNF inhibitor, followed by an IL-17A agent and 2 TNF inhibitors, respectively. CONCLUSIONS Study findings suggested that all treatment strategies with biologics, TNF inhibitors or IL-17A antibody agents, in the treatment guidelines for AS were not cost-effective at the common WTP of $100,000 per QALY. However, the sequential treatment with 1 TNF inhibitor followed by an IL-17A antibody agent was considered cost-effective at a higher WTP of $150,000 per QALY. DISCLOSURES No outside funding supported this study. The authors have nothing to disclose. Primary findings of this study were presented in part at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) in Baltimore, MD, May 2018.
Collapse
Affiliation(s)
- Quang A. Le
- Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, California
| | - Jenny H. Kang
- Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, California
| | - Sun Lee
- Department of Clinical Sciences, Fred Wilson School of Pharmacy, High Point University, High Point, North Carolina
| | - Dimittri Delevry
- Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, California
| |
Collapse
|
20
|
Thompson JC, Wanderman N, Anderson PA, Freedman BA. Abaloparatide and the Spine: A Narrative Review. Clin Interv Aging 2020; 15:1023-1033. [PMID: 32636617 PMCID: PMC7334019 DOI: 10.2147/cia.s227611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/23/2020] [Indexed: 11/23/2022] Open
Abstract
Osteoporosis is a common and debilitating condition characterized by diminished bone mass and architecture leading to bone fragility. Antiresorptive medicines like bisphosphonates (and less commonly denosumab) are the typical first-line agents for the medical treatment of osteoporosis. However, newer anabolic agents have been shown to improve bone mass and architecture, as well as reduce fracture risk, to a greater degree than traditional antiresorptive therapies. Teriparatide (human recombinant parathyroid hormone (PTH) 1–34, Forteo, Ely Lilly, Indianapolis, IN), which was the first in class to be approved in the United States, is the most widely used anabolic osteoporosis medicine and has shown significant benefit over traditional antiresorptive therapies. However, abaloparatide (synthetic parathyroid-related peptide (PTHrP), Tymlos, Radius Health, Waltham, MA), the second drug in this family, has recently become available for use. In this narrative review, we review the mechanism, effects, and benefits of abaloparatide compared to alternative treatments as well as discuss the current literature in regard to its effect on osteoporosis-related complications in the spine.
Collapse
Affiliation(s)
| | - Nathan Wanderman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Paul A Anderson
- Department of Orthopaedic Surgery, Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin, Madison, WI 53705-2281, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
21
|
Corro Ramos I, Hoogendoorn M, Rutten-van Mölken MPMH. How to Address Uncertainty in Health Economic Discrete-Event Simulation Models: An Illustration for Chronic Obstructive Pulmonary Disease. Med Decis Making 2020; 40:619-632. [PMID: 32608322 PMCID: PMC7401182 DOI: 10.1177/0272989x20932145] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 04/16/2020] [Indexed: 12/18/2022]
Abstract
Background. Evaluation of personalized treatment options requires health economic models that include multiple patient characteristics. Patient-level discrete-event simulation (DES) models are deemed appropriate because of their ability to simulate a variety of characteristics and treatment pathways. However, DES models are scarce in the literature, and details about their methods are often missing. Methods. We describe 4 challenges associated with modeling heterogeneity and structural, stochastic, and parameter uncertainty that can be encountered during the development of DES models. We explain why these are important and how to correctly implement them. To illustrate the impact of the modeling choices discussed, we use (results of) a model for chronic obstructive pulmonary disease (COPD) as a case study. Results. The results from the case study showed that, under a correct implementation of the uncertainty in the model, a hypothetical intervention can be deemed as cost-effective. The consequences of incorrect modeling uncertainty included an increase in the incremental cost-effectiveness ratio ranging from 50% to almost a factor of 14, an extended life expectancy of approximately 1.4 years, and an enormously increased uncertainty around the model outcomes. Thus, modeling uncertainty incorrectly can have substantial implications for decision making. Conclusions. This article provides guidance on the implementation of uncertainty in DES models and improves the transparency of reporting uncertainty methods. The COPD case study illustrates the issues described in the article and helps understanding them better. The model R code shows how the uncertainty was implemented. For readers not familiar with R, the model's pseudo-code can be used to understand how the model works. By doing this, we can help other developers, who are likely to face similar challenges to those described here.
Collapse
Affiliation(s)
- Isaac Corro Ramos
- Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - Martine Hoogendoorn
- Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - Maureen P. M. H. Rutten-van Mölken
- />Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
- />Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
22
|
Mori T, Crandall CJ, Ganz DA. Cost-Effectiveness of Sequential Teriparatide/Alendronate Versus Alendronate-Alone Strategies in High-Risk Osteoporotic Women in the US: Analyzing the Impact of Generic/Biosimilar Teriparatide. JBMR Plus 2019; 3:e10233. [PMID: 31768491 PMCID: PMC6874180 DOI: 10.1002/jbm4.10233] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/08/2019] [Accepted: 08/19/2019] [Indexed: 01/08/2023] Open
Abstract
Teriparatide, currently only available in brand form in the United States, is a costly drug approved for the treatment of postmenopausal osteoporotic women who are at high risk of fracture. Because market exclusivity for brand teriparatide expired in August 2019 in the US, we sought to understand the potential health economic impact of the availability of generic or biosimilar (generic/biosimilar) teriparatide. We examined the cost‐effectiveness of daily teriparatide for 2 years followed by weekly alendronate for 10 years (ie, sequential teriparatide/alendronate) compared with alendronate alone for 10 years in community‐dwelling white osteoporotic women with prior vertebral fracture at ages 65, 70, 75, and 80. Using an updated version of previously validated Markov microsimulation models, we obtained incremental cost‐effectiveness ratios (ICERs) (dollars [$] per quality‐adjusted life year [QALY]) with a willingness‐to‐pay (WTP) of $150,000 per QALY from a societal perspective with a lifelong time horizon. In the base case, we estimated the annual cost of teriparatide to be $20,161, based on the assumption of 10% brand usage (at a cost of $27,618) and 90% generic/biosimilar usage (priced 30% lower than brand). The ICERs of sequential teriparatide/alendronate compared with alendronate alone were greater than $280,000 per QALY at all ages examined. In deterministic sensitivity analyses, results were sensitive to teriparatide's cost, with the cost of a generic/biosimilar product needing to be 65% to 85% lower than brand for sequential teriparatide/alendronate to be cost‐effective. In probabilistic sensitivity analyses, under the assumption that the annual cost of teriparatide was $20,161, the probabilities of sequential teriparatide/alendronate being cost‐effective were less than 4% at a WTP of $150,000 per QALY. In conclusion, among community‐dwelling older osteoporotic women with prior vertebral fracture in the US, even with the potential availability of generic/biosimilar teriparatide, sequential teriparatide/alendronate would not be cost‐effective unless the cost of generic/biosimilar teriparatide were heavily discounted with respect to the current brand cost. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
Collapse
Affiliation(s)
- Takahiro Mori
- Department of Health Services Research, Faculty of Medicine University of Tsukuba Tsukuba Ibaraki Japan.,Health Services Research and Development Center University of Tsukuba Tsukuba Ibaraki Japan.,Department of General Internal Medicine Eastern Chiba Medical Center Togane Chiba Japan
| | - Carolyn J Crandall
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine University of California, Los Angeles Los Angeles CA USA
| | - David A Ganz
- Geriatric Research, Education and Clinical Center and HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System Los Angeles CA USA.,Division of Geriatrics, Department of Medicine, David Geffen School of Medicine University of California, Los Angeles Los Angeles CA USA.,Health Unit RAND Corporation Santa Monica CA USA
| |
Collapse
|
23
|
Merlotti D, Falchetti A, Chiodini I, Gennari L. Efficacy and safety of abaloparatide for the treatment of post-menopausal osteoporosis. Expert Opin Pharmacother 2019; 20:805-811. [DOI: 10.1080/14656566.2019.1583208] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- D. Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - A. Falchetti
- EndOsMet, Villa Donatello Private Hospital, Florence, Italy
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - I. Chiodini
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Medical Science and Community Health, University of Milan, Milan, Italy
| | - L. Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| |
Collapse
|