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Carrillo de Albornoz S, Higgins AM, Petrie D, Irving A, Fanning L, Weinkove R, Crispin P, Dendle C, Gilbertson M, Johnston A, Keegan A, Pepperell D, Pullon H, Reynolds J, van Tonder T, Trotman J, Waters N, Wellard C, Weston H, Morrissey CO, Wood EM, McQuilten ZK. Economic evaluation: immunoglobulin vs prophylactic antibiotics in hypogammaglobulinemia and hematological malignancies. Blood Adv 2024; 8:2259-2267. [PMID: 38484199 DOI: 10.1182/bloodadvances.2023012047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/06/2024] [Indexed: 05/15/2024] Open
Abstract
ABSTRACT Patients with hematological malignancies are at high risk of developing hypogammaglobulinemia (HGG) and infections. Immunoglobulin (Ig) is one recommended option to prevent these infections, but it is expensive, and its cost-effectiveness compared with other prevention strategies remains unknown. We conducted a trial-based economic evaluation from the Australian health care system perspective to estimate the 12-month cost-effectiveness of prophylactic Ig vs prophylactic antibiotics in 63 adults with HGG and hematological malignancies participating in the RATIONAL feasibility trial. Two analyses were conducted: (1) cost-utility analysis to assess the incremental cost per quality-adjusted life year (QALY) gained; and (2) cost-effectiveness analysis to assess the incremental cost per serious infection prevented (grade ≥3) and per any infection (any grade) prevented. Over 12 months, the total cost per patient was significantly higher in the Ig group than in the antibiotic group (mean difference, AU$29 140; P < .001). Most patients received IVIg, which was the main cost driver; only 2 patients in the intervention arm received subcutaneous Ig. There were nonsignificant differences in health outcomes. Results showed Ig was more costly than antibiotics and associated with fewer QALYs. The incremental cost-effectiveness ratio of Ig vs antibiotics was AU$111 262 per serious infection prevented, but Ig was more costly and associated with more infections when all infections were included. On average and for this patient population, Ig prophylaxis may not be cost-effective compared with prophylactic antibiotics. Further research is needed to confirm these findings in a larger population and considering longer-term outcomes. The trial was registered at the Australian and New Zealand Clinical Trials Registry as #ACTRN12616001723471.
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Affiliation(s)
- Sara Carrillo de Albornoz
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Centre for Health Economics, Monash University, Melbourne, Australia
| | - Alisa M Higgins
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dennis Petrie
- Centre for Health Economics, Monash University, Melbourne, Australia
| | - Adam Irving
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Centre for Health Economics, Monash University, Melbourne, Australia
| | - Laura Fanning
- Centre for Health Economics, Monash University, Melbourne, Australia
| | - Robert Weinkove
- Te Rerenga Ora Wellington Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital, Coast & Hutt Valley, Wellington, New Zealand
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
- Department of Pathology & Molecular Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Philip Crispin
- Canberra Hospital, Canberra, Australia
- School of Medicine and Psychology, Australian National University, Canberra, Australia
| | - Claire Dendle
- Monash Infectious Diseases, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | | | - Anna Johnston
- Royal Hobart Hospital, Hobart, Australia
- University of Tasmania, Hobart, Australia
| | - Anastazia Keegan
- PathWest Laboratory Medicine, King Edward Memorial Hospital, Perth, Australia
| | | | - Humphrey Pullon
- Department of Haematology, Waikato Hospital, Hamilton, New Zealand
| | - John Reynolds
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Tina van Tonder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Judith Trotman
- Concord Repatriation General Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Neil Waters
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Cameron Wellard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Helen Weston
- Sunshine Coast University Hospital, Sunshine Coast, Australia
| | - C Orla Morrissey
- Central Clinical School, Monash University, Melbourne, Australia
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia
| | - Erica M Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Zoe K McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Haematology, Monash Health, Melbourne, Australia
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McQuilten ZK, Weinkove R, Thao LTP, Crispin P, Degelia A, Dendle C, Gilbertson M, Johnston A, Keegan A, Pepperell D, Pullon H, Reynolds J, van Tonder T, Trotman J, Waters N, Wellard C, Weston H, Morrissey CO, Wood EM. Immunoglobulin replacement vs prophylactic antibiotics for hypogammaglobulinemia secondary to hematological malignancy. Blood Adv 2024; 8:1787-1795. [PMID: 38592710 PMCID: PMC11006812 DOI: 10.1182/bloodadvances.2023011231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/20/2023] [Indexed: 04/10/2024] Open
Abstract
ABSTRACT Immunoglobulin replacement and prophylactic antibiotics are commonly used to prevent infections in patients with secondary hypogammaglobulinemia due to hematological malignancies but have never been directly compared. In this randomized controlled feasibility trial conducted in 7 hospitals in Australia and New Zealand, we enrolled patients with secondary hypogammaglobulinemia with either a history of recurrent/severe infection or an immunoglobulin G level <4 g/L. Participants were randomized in a 1:2 ratio to immunoglobulin (0.4 g/kg per 4 weeks IV) or daily antibiotics (trimethoprim-sulfamethoxazole 160 mg/800 mg or, if contraindicated, 100 mg doxycycline) for 12 months. Participants allocated to antibiotics were allowed to crossover after grade ≥3 infections. The primary outcome was proportion of patients alive on the assigned treatment 12 months after randomization. Between August 2017 and April 2019, 63 patients were randomized: 42 to antibiotics and 21 to immunoglobulin. Proportion of participants alive on allocated treatment at 12 months was 76% in the immunoglobulin and 71% in the antibiotic arm (Fisher exact test P=.77; odds ratio, 0.78; 95% CI, 0.22-2.52). The lower quartile for time to first major infection (median, not reached) was 11.1 months for the immunoglobulin and 9.7 months for the antibiotic arm (log-rank test, P=.65). Three participants in the immunoglobulin and 2 in the antibiotic arm had grade ≥3 treatment-related adverse events. A similar proportion of participants remained on antibiotic prophylaxis at 12 months to those on immunoglobulin, with similar rates of major infections. Our findings support the feasibility of progressing to a phase 3 trial. Trial registration #ACTRN12616001723471.
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Affiliation(s)
- Zoe K. McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Haematology, Monash Health, Melbourne, Australia
| | - Robert Weinkove
- Te Rerenga Ora Wellington Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital, Coast & Hutt Valley, Wellington, New Zealand
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
- Department of Pathology & Molecular Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Le Thi Phuong Thao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Philip Crispin
- Department of Haematology, Canberra Hospital, Canberra, Australia
| | - Amber Degelia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Claire Dendle
- Monash Infectious Diseases, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | | | - Anna Johnston
- Department of Haematology, Royal Hobart Hospital, Hobart, Australia
- Department of Medicine, University of Tasmania, Hobart, Australia
| | - Anastazia Keegan
- PathWest Laboratory Medicine, King Edward Memorial Hospital, Perth, Australia
| | | | - Humphrey Pullon
- Department of Haematology, Waikato Hospital, Hamilton, New Zealand
| | - John Reynolds
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Tina van Tonder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Judith Trotman
- Department of Haematology, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
| | - Neil Waters
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Cameron Wellard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Helen Weston
- Department of Haematology, Sunshine Coast University Hospital, Sunshine Coast, Australia
| | - C. Orla Morrissey
- Central Clinical School, Monash University, Melbourne, Australia
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia
| | - Erica M. Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Haematology, Monash Health, Melbourne, Australia
| | - Australasian Leukaemia and Lymphoma Group
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Haematology, Monash Health, Melbourne, Australia
- Te Rerenga Ora Wellington Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital, Coast & Hutt Valley, Wellington, New Zealand
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
- Department of Pathology & Molecular Medicine, University of Otago Wellington, Wellington, New Zealand
- Department of Haematology, Canberra Hospital, Canberra, Australia
- Monash Infectious Diseases, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
- Department of Haematology, Royal Hobart Hospital, Hobart, Australia
- Department of Medicine, University of Tasmania, Hobart, Australia
- PathWest Laboratory Medicine, King Edward Memorial Hospital, Perth, Australia
- Department of Haematology, Fiona Stanley Hospital, Perth, Australia
- Department of Haematology, Waikato Hospital, Hamilton, New Zealand
- Central Clinical School, Monash University, Melbourne, Australia
- Department of Haematology, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
- Department of Haematology, Sunshine Coast University Hospital, Sunshine Coast, Australia
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia
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Kulasekararaj AG, Lehtinen AE, Forsyth C, Gandhi S, Griffin M, Körper S, Mikala G, Muus P, Overgaard U, Patriquin CJ, Pullon H, Shen YM, Spearing R, Szer J, De la Borderie G, Duda PW, Farzaneh-Far R, Ragunathan S, Sayegh CE, Vadysirisack DD, Schrezenmeier H. Phase II trials of zilucoplan in paroxysmal nocturnal hemoglobinuria. Haematologica 2024; 109:929-935. [PMID: 37534517 PMCID: PMC10905099 DOI: 10.3324/haematol.2022.281780] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 07/27/2023] [Indexed: 08/04/2023] Open
Affiliation(s)
- Austin G Kulasekararaj
- King's College Hospital-NHS Foundation Trust, NIHR/Wellcome King's Clinical Research Facility, London, UK and King's College London, London
| | - Anna-Elina Lehtinen
- Helsinki University Hospital Comprehensive Cancer Center and University of Helsinki, Helsinki
| | | | - Shreyans Gandhi
- King's College Hospital-NHS Foundation Trust, NIHR/Wellcome King's Clinical Research Facility, London, UK and King's College London, London
| | | | - Sixten Körper
- University of Ulm, Institute of Transfusion Medicine, and Institute of Transfusion Medicine and Immunogenetics Ulm, Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and University Hospital Ulm, Ulm
| | - Gabor Mikala
- Central Hospital of Southern Pest National Institute of Hematology and Infectious Diseases, Budapest
| | - Petra Muus
- King's College Hospital-NHS Foundation Trust, NIHR/Wellcome King's Clinical Research Facility, London, UK and King's College London, London, UK; St. James's University Hospital, Leeds
| | | | | | | | | | | | - Jeff Szer
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC
| | | | | | | | | | | | | | - Hubert Schrezenmeier
- University of Ulm, Institute of Transfusion Medicine, and Institute of Transfusion Medicine and Immunogenetics Ulm, Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and University Hospital Ulm, Ulm.
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Mehdi DE, Grossi FV, Deschatelets P, Pullon H, Tan L, Vega CA, Francois CG. APL-2, a complement C3 inhibitor, may potentially reduce both intravascular and extravascular hemolysis in patients with paroxysmal nocturnal hemoglobinuria. Mol Immunol 2017. [DOI: 10.1016/j.molimm.2017.06.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chiu W, Pullon H, Woon ST, Oei P, The R, Ameratunga R. IgE-type multiple myeloma with the late development of IgA2 kappa and plasma cell leukaemia. Pathology 2010; 42:82-4. [DOI: 10.3109/00313020903434660] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Jarrett P, Rademaker M, Havill J, Pullon H. Toxic epidermal necrolysis treated with cyclosporin and granulocyte colony stimulating factor. Clin Exp Dermatol 1997; 22:146-7. [PMID: 9425696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A patient developed toxic epidermal necrolysis while on carbamazepine, 80% of her skin surface being involved. She also developed a pancytopenia with a neutropenia of 0.77 x 10(9)/l (normal range 2-7.5 x 10(9)/l), but was treated with cyclosporin and granulocyte colony stimulating factor and made a full recovery.
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Affiliation(s)
- P Jarrett
- Department of Dermatology, Health Waikato, New Zealand
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Brito-Babapulle F, Pullon H, Layton DM, Etches A, Huxtable A, Mangi M, Bellingham AJ, Mufti GJ. Clinicopathological features of acute undifferentiated leukaemia with a stem cell phenotype. Br J Haematol 1990; 76:210-4. [PMID: 2094323 DOI: 10.1111/j.1365-2141.1990.tb07873.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Over a 4 1/2-year period, 141 patients with acute leukaemia had morphologic, immunophenotypic and cytochemical studies performed at King's College Hospital. Seven cases were noted to have blast cells which did not express myeloid or lymphoid antigens or cytochemical staining indicative of differentiation but were HLA DR and CD 34 positive. Based on these criteria we have used the term stem cell acute leukaemia to denote these patients. There were five women and two men with a median age of 61 years (16-86). Presentation marrows were heavily infiltrated with blasts (greater than 95% in 6/7) which were usually pleomorphic. Type 2 blasts. Auer rods and dysplastic features were absent. Two of six cases studied showed clonal karyotypic abnormalities. Four patients were treated with high dose chemotherapy. Three of these achieved a complete remission but relapsed at 3, 6 and 7 months respectively. The median survival of the group was 7 months (2-12). We conclude that the stem cell acute leukaemias are a distinct clinicomorphological group which appear to have a poor prognosis with conventional chemotherapy.
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Affiliation(s)
- F Brito-Babapulle
- Department of Haematological Medicine, Kings College School of Medicine and Dentistry, London
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Abstract
A patient whose second, third and fourth pregnancies were complicated by alloimmune thrombocytopenia, developed pemphigoid gestationis after the fourth pregnancy. The infant was delivered by Caesarean section at 34 weeks gestation. The pemphigoid gestationis resolved promptly after a short course of systemic corticosteroids. A possible association between these two uncommon conditions is discussed.
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Affiliation(s)
- B Adriaans
- Department of Dermatology, King's College Hospital, Denmark Hill, London, UK
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