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Haasova M, Snowsill T, Jones-Hughes T, Crathorne L, Cooper C, Varley-Campbell J, Mujica-Mota R, Coelho H, Huxley N, Lowe J, Dudley J, Marks S, Hyde C, Bond M, Anderson R. Immunosuppressive therapy for kidney transplantation in children and adolescents: systematic review and economic evaluation. Health Technol Assess 2018; 20:1-324. [PMID: 27557331 DOI: 10.3310/hta20610] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND End-stage renal disease is a long-term irreversible decline in kidney function requiring kidney transplantation, haemodialysis or peritoneal dialysis. The preferred option is kidney transplantation followed by induction and maintenance immunosuppressive therapy to reduce the risk of kidney rejection and prolong graft survival. OBJECTIVES To systematically review and update the evidence for the clinical effectiveness and cost-effectiveness of basiliximab (BAS) (Simulect,(®) Novartis Pharmaceuticals) and rabbit antihuman thymocyte immunoglobulin (Thymoglobuline,(®) Sanofi) as induction therapy and immediate-release tacrolimus [Adoport(®) (Sandoz); Capexion(®) (Mylan); Modigraf(®) (Astellas Pharma); Perixis(®) (Accord Healthcare); Prograf(®) (Astellas Pharma); Tacni(®) (Teva); Vivadex(®) (Dexcel Pharma)], prolonged-release tacrolimus (Advagraf,(®) Astellas Pharma); belatacept (BEL) (Nulojix,(®) Bristol-Myers Squibb), mycophenolate mofetil (MMF) [Arzip(®) (Zentiva), CellCept(®) (Roche Products), Myfenax(®) (Teva), generic MMF is manufactured by Accord Healthcare, Actavis, Arrow Pharmaceuticals, Dr Reddy's Laboratories, Mylan, Sandoz and Wockhardt], mycophenolate sodium, sirolimus (Rapamune,(®) Pfizer) and everolimus (Certican,(®) Novartis Pharmaceuticals) as maintenance therapy in children and adolescents undergoing renal transplantation. DATA SOURCES Clinical effectiveness searches were conducted to 7 January 2015 in MEDLINE (via Ovid), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (via Wiley Online Library) and Web of Science [via Institute for Scientific Information (ISI)], Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Health Technology Assessment (HTA) (The Cochrane Library via Wiley Online Library) and Health Management Information Consortium (via Ovid). Cost-effectiveness searches were conducted to 15 January 2015 using a costs or economic literature search filter in MEDLINE (via Ovid), EMBASE (via Ovid), NHS Economic Evaluation Databases (via Wiley Online Library), Web of Science (via ISI), Health Economic Evaluations Database (via Wiley Online Library) and EconLit (via EBSCOhost). REVIEW METHODS Titles and abstracts were screened according to predefined inclusion criteria, as were full texts of identified studies. Included studies were extracted and quality appraised. Data were meta-analysed when appropriate. A new discrete time state transition economic model (semi-Markov) was developed; graft function, and incidences of acute rejection and new-onset diabetes mellitus were used to extrapolate graft survival. Recipients were assumed to be in one of three health states: functioning graft, graft loss or death. RESULTS Three randomised controlled trials (RCTs) and four non-RCTs were included. The RCTs only evaluated BAS and tacrolimus (TAC). No statistically significant differences in key outcomes were found between BAS and placebo/no induction. Statistically significantly higher graft function (p < 0.01) and less biopsy-proven acute rejection (odds ratio 0.29, 95% confidence interval 0.15 to 0.57) was found between TAC and ciclosporin (CSA). Only one cost-effectiveness study was identified, which informed NICE guidance TA99. BAS [with TAC and azathioprine (AZA)] was predicted to be cost-effective at £20,000-30,000 per quality-adjusted life year (QALY) versus no induction (BAS was dominant). BAS (with CSA and MMF) was not predicted to be cost-effective at £20,000-30,000 per QALY versus no induction (BAS was dominated). TAC (with AZA) was predicted to be cost-effective at £20,000-30,000 per QALY versus CSA (TAC was dominant). A model based on adult evidence suggests that at a cost-effectiveness threshold of £20,000-30,000 per QALY, BAS and TAC are cost-effective in all considered combinations; MMF was also cost-effective with CSA but not TAC. LIMITATIONS The RCT evidence is very limited; analyses comparing all interventions need to rely on adult evidence. CONCLUSIONS TAC is likely to be cost-effective (vs. CSA, in combination with AZA) at £20,000-30,000 per QALY. Analysis based on one RCT found BAS to be dominant, but analysis based on another RCT found BAS to be dominated. BAS plus TAC and AZA was predicted to be cost-effective at £20,000-30,000 per QALY when all regimens were compared using extrapolated adult evidence. High-quality primary effectiveness research is needed. The UK Renal Registry could form the basis for a prospective primary study. STUDY REGISTRATION This study is registered as PROSPERO CRD42014013544. FUNDING The National Institute for Health Research HTA programme.
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Affiliation(s)
- Marcela Haasova
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Tristan Snowsill
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Tracey Jones-Hughes
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Louise Crathorne
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Chris Cooper
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Jo Varley-Campbell
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Ruben Mujica-Mota
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Helen Coelho
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Nicola Huxley
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Jenny Lowe
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Jan Dudley
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children (University Hospitals Bristol NHS Foundation Trust), Bristol, UK
| | - Stephen Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Chris Hyde
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Mary Bond
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Rob Anderson
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
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Desai VCA, Ferrand Y, Cavanaugh TM, Kelton CML, Caro JJ, Goebel J, Heaton PC. Comparative Effectiveness of Tacrolimus-Based Steroid Sparing versus Steroid Maintenance Regimens in Kidney Transplantation: Results from Discrete Event Simulation. Med Decis Making 2017; 37:827-843. [DOI: 10.1177/0272989x17700879] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background. Corticosteroids used as immunosuppressants to prevent acute rejection (AR) and graft loss (GL) following kidney transplantation are associated with serious cardiovascular and other adverse events. Evidence from short-term randomized controlled trials suggests that many patients on a tacrolimus-based immunosuppressant regimen can withdraw from steroids without increased AR or GL risk. Objectives. To measure the long-term tradeoff between GL and adverse events for a heterogeneous-risk population and determine the optimal timing of steroid withdrawal. Methods. A discrete event simulation was developed including, as events, AR, GL, myocardial infarction (MI), stroke, cytomegalovirus, and new onset diabetes mellitus (NODM), among others. Data from the United States Renal Data System were used to estimate event-specific parametric regressions, which accounted for steroid-sparing regimen (avoidance, early 7-d withdrawal, 6-mo withdrawal, 12-mo withdrawal, and maintenance) as well as patients’ demographics, immunologic risks, and comorbidities. Regression-equation results were used to derive individual time-to-event Weibull distributions, used, in turn, to simulate the course of patients over 20 y. Results. Patients on steroid avoidance or an early-withdrawal regimen were more likely to experience AR (45.9% to 55.0% v. 33.6%, P < 0.05) and GL (51.5% to 68.8% v. 37.8%, P < 0.05) compared to patients on steroid maintenance. Patients in 6-mo and 12-mo steroid withdrawal groups were less likely to experience MI (11.1% v. 13.3%, P < 0.05), NODM (30.7% to 34.4% v. 37.7%, P < 0.05), and cardiac death (29.9% to 30.5% v. 32.4%, P < 0.05), compared to steroid maintenance. Conclusions. Strategies of 6- and 12-mo steroid withdrawal post-kidney transplantation are expected to reduce the rates of adverse cardiovascular events and other outcomes with no worsening of AR or GL rates compared with steroid maintenance.
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Affiliation(s)
- Vibha C. A. Desai
- Researcher, HealthCore, Andover, MA, USA (VCAD)
- Assistant Professor of Operations Management, College of Business, Clemson University, Clemson, SC, USA (YF)
- Assistant Professor of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (TMC)
- Professor of Economics, Carl H. Lindner College of Business, and Adjunct Professor of Clinical Pharmacy, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (CMLK)
- Chief Scientist, Evidera, and Adjunct Professor of Epidemiology and of Medicine, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada (JJC)
| | - Yann Ferrand
- Researcher, HealthCore, Andover, MA, USA (VCAD)
- Assistant Professor of Operations Management, College of Business, Clemson University, Clemson, SC, USA (YF)
- Assistant Professor of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (TMC)
- Professor of Economics, Carl H. Lindner College of Business, and Adjunct Professor of Clinical Pharmacy, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (CMLK)
- Chief Scientist, Evidera, and Adjunct Professor of Epidemiology and of Medicine, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada (JJC)
| | - Teresa M. Cavanaugh
- Researcher, HealthCore, Andover, MA, USA (VCAD)
- Assistant Professor of Operations Management, College of Business, Clemson University, Clemson, SC, USA (YF)
- Assistant Professor of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (TMC)
- Professor of Economics, Carl H. Lindner College of Business, and Adjunct Professor of Clinical Pharmacy, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (CMLK)
- Chief Scientist, Evidera, and Adjunct Professor of Epidemiology and of Medicine, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada (JJC)
| | - Christina M. L. Kelton
- Researcher, HealthCore, Andover, MA, USA (VCAD)
- Assistant Professor of Operations Management, College of Business, Clemson University, Clemson, SC, USA (YF)
- Assistant Professor of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (TMC)
- Professor of Economics, Carl H. Lindner College of Business, and Adjunct Professor of Clinical Pharmacy, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (CMLK)
- Chief Scientist, Evidera, and Adjunct Professor of Epidemiology and of Medicine, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada (JJC)
| | - J. Jaime Caro
- Researcher, HealthCore, Andover, MA, USA (VCAD)
- Assistant Professor of Operations Management, College of Business, Clemson University, Clemson, SC, USA (YF)
- Assistant Professor of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (TMC)
- Professor of Economics, Carl H. Lindner College of Business, and Adjunct Professor of Clinical Pharmacy, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (CMLK)
- Chief Scientist, Evidera, and Adjunct Professor of Epidemiology and of Medicine, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada (JJC)
| | - Jens Goebel
- Researcher, HealthCore, Andover, MA, USA (VCAD)
- Assistant Professor of Operations Management, College of Business, Clemson University, Clemson, SC, USA (YF)
- Assistant Professor of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (TMC)
- Professor of Economics, Carl H. Lindner College of Business, and Adjunct Professor of Clinical Pharmacy, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (CMLK)
- Chief Scientist, Evidera, and Adjunct Professor of Epidemiology and of Medicine, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada (JJC)
| | - Pamela C. Heaton
- Researcher, HealthCore, Andover, MA, USA (VCAD)
- Assistant Professor of Operations Management, College of Business, Clemson University, Clemson, SC, USA (YF)
- Assistant Professor of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (TMC)
- Professor of Economics, Carl H. Lindner College of Business, and Adjunct Professor of Clinical Pharmacy, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA (CMLK)
- Chief Scientist, Evidera, and Adjunct Professor of Epidemiology and of Medicine, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada (JJC)
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