[Cost-effectiveness of buccal midazolam in the treatment of prolonged convulsive seizures in the outpatient setting in Spain]

INTRODUCTION

To be able to treat prolonged epileptic crises practical, safe and effective rescue medication is needed. Today, the standard treatment in community healthcare is rectal diazepam. The introduction of a buccal solution of midazolam opens up a new perspective in their treatment.

AIMS

To evaluate the cost-effectiveness of buccal midazolam with respect to rectal diazepam for children diagnosed with epilepsy who present prolonged convulsive seizures in the community setting in Spain.

MATERIALS AND METHODS

The study produces a model of its cost-effectiveness from the perspective of the Spanish National Health System (SNS), with the outcomes presented in terms of cost-quality adjusted life years. Data were collected from different sources, including estimations regarding the clinical effectiveness from a clinical trial, from a Delphi panel in Spain and from a national survey carried out on parents of children with epilepsy in order to determine the current practices.

RESULTS

Treatment with buccal midazolam produces a saving in costs in comparison to rectal diazepam. The amount saved by the Spanish SNS comes to 5,484 euros per patient per year. Treatment with buccal midazolam offers an improved health-related quality of life. This, together with the savings in costs, means that there is a dominance of buccal midazolam over rectal diazepam in all the settings that have been examined.

CONCLUSIONS

The results obtained with the model show that buccal midazolam is more cost-effective than rectal diazepam due to a reduction in the need to call out ambulances and for stays in hospital, as well as an improved health-related quality of life.

Cost-effectiveness of venlafaxine XL compared with diazepam in the treatment of generalised anxiety disorder in the United Kingdom

This study used decision modelling to compare the cost-effectiveness of venlafaxine XL (Efexor XL) to that of diazepam to treat non-depressed patients suffering from generalised anxiety disorder (GAD), from the perspective of the United Kingdom's National Health Service (NHS). Starting treatment with venlafaxine XL instead of diazepam significantly increased the expected probability of being in remission by 83% at 6 months (from 16.8% to 30.7%), and the expected probability of relapsing at 6 months was decreased by 79% (from 16.9% to 3.5%). The expected 6-month NHS cost of using venlafaxine XL to treat GAD was estimated to be pounds sterling 353 compared to pounds sterling 311 with diazepam. Hence starting GAD treatment with venlafaxine XL (75 mg per day) instead of diazepam (5 mg three times per day) is clinically more effective and the cost-effective strategy for managing non-depressed patients suffering from GAD in the UK.

Diazepam or midazolam for external DC cardioversion (The DORM Study)

AIMS

To compare the clinical efficacy and tolerability of two intravenous sedatives for physician-led DC cardioversion of atrial arrhythmias.

METHODS AND RESULTS

One hundred and forty-one patients attending for elective DC cardioversion of atrial arrhythmias were randomized to intravenous midazolam or diazepam. Sedation was administered using titration protocols. Procedure times, operator satisfaction scores and adverse events were documented. The patients immediate, 24- and 48-h recall and awareness of after-effects were obtained from questionnaires. Seventy-one patients received midazolam (mean 12.5 mg) and 70 patients received diazepam (mean 28.1 mg). There were 16 minor adverse events with midazolam (20% hypotension, 3% oxygen desaturation) and nine with diazepam (7% hypotension, 6% required additional analgesia), P = 0.14. There were no major adverse events. Sedation time was 5.0 +/- 3.4 min for midazolam and 6.5 +/- 3.4 min for diazepam (P = 0.0016). Patients awoke 77 +/- 46 min post-sedation with midazolam and 39 +/- 24 min with diazepam (P < 0.0001). There was no recall of the procedure at 48 h and no difference in awareness of after-effects between the two groups at 24 or 48 h, P = ns.

CONCLUSION

Physician-led cardioversion of atrial arrhythmias using intravenous sedation is effective and well tolerated. Sedation with diazepam was associated with fewer minor adverse events and a quicker recovery time than midazolam.

A comparison of lorazepam and diazepam as initial therapy in convulsive status epilepticus

BACKGROUND

Previous trials have suggested lorazepam may be superior to diazepam as first-line treatment of convulsive status epilepticus (CSE), with improved seizure outcome, and a lower incidence of side-effects. Many published guidelines however still recommend diazepam.

AIM

To compare the efficacy, safety and cost of lorazepam compared to diazepam, in adults with CSE.

DESIGN

Retrospective case note audit.

METHODS

Cases of CSE were retrospectively identified over two 18-month periods either side of the introduction of a new management protocol in May 1997, in which lorazepam 4 mg i.v. was substituted for diazepam 10 mg i.v. as first-line treatment for CSE. Diagnostic codes for all admissions and casualty presentations of patients over 16 years of age were examined for primary or secondary codes including 'epilepsy', 'fits' or 'status epilepticus'. Medical records and casualty notes were reviewed to identify CSE cases. Treatment groups were compared using ANOVA and a Tukey post hoc analysis. Treatment success was defined as cessation of seizures without recurrence in the subsequent 12 h.

RESULTS

In both premonitory and established CSE, both drugs were equally effective at terminating seizures, but significantly fewer seizure recurrences followed lorazepam, and fewer repeat doses were needed. There were no differences in reported adverse events or in drug costs.

DISCUSSION

We recommend that lorazepam be the first-line therapy in preference to diazepam in adults with CSE.

Treatment of febrile seizures: the influence of treatment efficacy and side-effect profile on value to parents

OBJECTIVES

We examined parents' perception of the value of treatments designed to reduce the risk of febrile seizure recurrence.

STUDY DESIGN

The families of 42 children with febrile seizures were recruited after pediatric or neuropediatric consultation. A mail questionnaire addressed the family's willingness to pay for a hypothetical treatment for febrile seizures with risk reductions for future febrile seizures of 25%, 50%, 75%, and 100%. The hypothetical clinical scenario was then modified to include the side- effect profiles of either daily phenobarbital or valproic acid, or intermittent diazepam prophylaxis. Covariates included the nature of the child's febrile seizure(s), parents' familiarity with febrile seizures, experiences at the time of febrile seizures or with medication side effects, education and income, and mastery and trait anxiety.

RESULTS

Thirty-eight parents, representing 22 of 42 families, completed questionnaires. There was a dramatic inflection in parents' willingness to pay for 100% risk reduction as opposed to 75% or lower risk reductions. Introduction of side effects dramatically reduced the value attached to each level of treatment benefit. Nevertheless, a few parents (3/38) would pay "as much as it takes" to be rid of their child's recurrence risk.

CONCLUSIONS

Given the range of value assigned to prophylactic medication for febrile seizures, management strategies for children with febrile seizures must be responsive to the needs and values of individual families.

A behavioral economic analysis of polydrug abuse in alcoholics: asymmetrical substitution of alcohol and cocaine

Economic concepts can be used to assess how drug prices affect consumption patterns. Increases in price for a commodity typically result in reductions in consumption. Demand is considered elastic if decreases in consumption are proportionally greater than increases in price, and inelastic if they are proportionally smaller than rises in price. The price of one commodity can also affect consumption of others. Commodities can function as substitutes, complements or independents, and these concepts refer to increases, decreases, or no change in the consumption of one item as the price of another increases. This study evaluated the effects of drug prices on hypothetical drug-purchasing decisions in 53 alcohol abusers. Experiments 1, 2, and 3 examined how alcohol, cocaine, and Valium prices, respectively, influenced purchases of alcohol, cocaine, Valium, heroin, marijuana and nicotine. As price of alcohol rose in Experiment 1, alcohol purchases decreased and demand for alcohol was inelastic. Cocaine was a complement to alcohol, but other drugs purchases were independent of alcohol prices. In Experiment 2, demand for cocaine was elastic as its price increased. Alcohol was a substitute for cocaine, but other drug purchases did not change significantly. In Experiment 3, demand for Valium was elastic as its price rose, and all other drug purchases were independent of Valium prices. Hypothetical choices were reliable between and within subjects and associated with urinalysis results and lifetime histories of drug abuse. These results suggest that, among alcohol abusers, cocaine is a complement to alcohol, but alcohol is a substitute for cocaine.

Pharmacoeconomic considerations in treatment options for acute seizures

Two pharmacoeconomic studies on the treatment of acute seizures have been conducted. In 1991, Kriel and colleagues surveyed parents of children with a history of cluster seizures, prolonged seizures, or status epilepticus who had been instructed in the use of rectal diazepam. A comparison of data before instruction with data after instruction showed a reduced need for emergency department visits with rectal diazepam. Instruction thus provided a pharmacoeconomic benefit, despite the cost of the product. In 1996, Marchetti and coworkers found that intravenous fosphenytoin was associated with fewer adverse events than intravenous phenytoin. Fosphenytoin thus reduced the need for adverse event management and provided a substantial pharmacoeconomic benefit, despite its higher cost, compared with phenytoin. This study had a number of limitations, however, and hospital pharmacists remain resistant to the use of fosphenytoin. Additional studies may provide more pharmacoeconomic data to support the greater use of fosphenytoin in the treatment of acute pediatric seizures.

Polydrug abuse in heroin addicts: a behavioral economic analysis

AIM

To assess how price and income affect hypothetical drug-purchasing decisions of polydrug abusers undergoing treatment for heroin addiction.

PARTICIPANTS, DESIGN AND SETTING

Forty subjects participated in experiments in which they hypothetically "purchased" drugs as price or income varied.

INTERVENTION

Experiment 1 examined effects of heroin price on purchases of heroin, valium, cocaine, marijuana and alcohol. Experiment 2 examined the effects of both heroin and valium prices on purchases of these drugs. In both these experiments, income remained constant. Experiment 3 examined the effects of increasing income on drug choices, with drug prices constant.

FINDINGS

As price of heroin rose in Experiment 1, heroin purchases decreased. Reductions in heroin purchases were proportionally less than price increases, demonstrating inelastic demand for heroin. Valium and cocaine purchases increased as heroin price rose, and cross-price elasticity coefficients indicated that these drugs substituted for heroin. In Experiment 2, demand for both heroin and valium was inelastic. Valium substituted for heroin, but heroin purchases were independent of valium prices, suggesting an asymmetrical substitution effect. Marijuana and alcohol purchases were independent of valium price, but both these drugs substituted for heroin. In Experiment 3 demand for heroin and cocaine was income elastic, with purchases rising in greater proportion than income. Marijuana, alcohol and valium purchases did not vary with income, demonstrating that demand for these drugs was income inelastic. Hypothetical choices were reliable both between and within subjects. Moreover, drug choices in this hypothetical situation were correlated with urinalysis results, demonstrating initial validity of this methodology.

CONCLUSIONS

This methodology may be useful for understanding the phenomenon of polydrug abuse.

Trends in the management of alcohol withdrawal syndrome

Alcohol use among head and neck cancer patients is common. Alcohol withdrawal (especially delirium tremens) poses significant potential morbidity to postsurgical patients. Treatment with newer benzodiazepines (BZDs) such as lorazepam and midazolam has become more widespread, and mortality rates from severe alcohol withdrawal have decreased in recent years. The authors retrospectively studied 102 patients with a diagnosis of alcohol withdrawal, including 20 patients undergoing surgery for cancer of the head and neck. There were 81 men and 21 women, with a mean (+/- standard deviation [SD]) age of 52.3 (+/- 16.1) years. Many of these patients (46%) were treated with more than one BZD or other neuroleptic, while 49% received single agent therapy of either chlordiazepoxide (26%) or lorazepam (23%). Delirium tremens occurred in 12% of all patients undergoing withdrawal and in 10% of head and neck cancer patients, with a mortality rate of 9% and 0%, respectively. Single agent use was successful in greater than 95% when either lorazepam or chlordiazepoxide was used. Instances of combination treatment where older BZDs were used yielded a 69% success rate. The higher complication rate and lower treatment success with combination treatment was multifactorial. Optimal management of the alcohol withdrawal syndrome requires an understanding of its pathophysiology and the principles of its prevention along with a familiarity of BZD pharmacokinetic drug profiles. The authors present a treatment plan which is cost-effective, keeps morbidity low, and should allow a continued decreasing trend in mortality rates from delirium tremens.

Cost of ICU sedation: comparison of empirical and controlled sedation methods

A randomised crossover study was undertaken to compare the quality and cost of controlled versus empirical sedation with midazolam in critically ill patients. Patients (n = 40) entering the ICU were enrolled provided they satisfied the strict entry criteria. During 90 hours of midazolam sedation, patients received randomly allocated 10-hour periods of controlled or empirical sedation. With empirical sedation, the mean dose of midazolam and the cost of sedation were almost double those with controlled sedation. The quality of sedation was superior with the controlled method. In a separate study on 352 patients, a cost-benefit analysis of controlled sedation with midazolam or propofol infusion or bolus injections of morphine plus diazepam showed that the quality of sedation achieved with propofol was superior to the other two regimens and that, with morphine plus diazepam, the quality of sedation was unacceptably poor. Although the direct purchase price of propofol was higher than that of other agents, the total cost of sedation with propofol was lower than that for midazolam for short-term intensive care (less than 24 hours) and comparable to midazolam for longer-term use. However, indirect benefits of sedation with propofol include a much shorter ICU stay with the attendant reduced nursing costs and greater throughout the patients, and this more than compensates for the higher purchase price of the agent.