Academic journal article Applied Health Economics and Health Policy

Cost-Utility Analysis of Duloxetine in Osteoarthritis: A US Private Payer Perspective

Academic journal article Applied Health Economics and Health Policy

Cost-Utility Analysis of Duloxetine in Osteoarthritis: A US Private Payer Perspective

Article excerpt

Published online: 25 April 2013

© Springer International Publishing Switzerland 2013


Background Duloxetine has recently been approved in the USA for chronic musculoskeletal pain, including osteoarthritis and chronic low back pain. The cost effectiveness of duloxetine in osteoarthritis has not previously been assessed. Duloxetine is targeted as post first-line (after acetaminophen) treatment of moderate to severe pain.

Objective The objective of this study was to estimate the cost effectiveness of duloxetine in the treatment of osteoarthritis from a US private payer perspective compared with other post first-line oral treatments, including non-steroidal anti-inflammatory drugs (NSAIDs), and both strong and weak opioids.

Methods A cost-utility analysis was performed using a discrete-state, time-dependent semi-Markov model based on the National Institute for Health and Clinical Excellence (NICE) model documented in its 2008 osteoarthritis guidelines. The model was extended for opioids by adding titration, discontinuation and additional adverse events (AEs). A life-long time horizon was adopted to capture the full consequences of NSAID-induced AEs. Fourteen health states comprised the structure of the model: treatment without persistent AE, six during-AE states, six post-AE states and death. Treatment-specific utilities were calculated using the transfer-to-utility method and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores from a meta-analysis of osteoarthritis clinical trials of 12 weeks and longer. Costs for 2011 were estimated using Red Book, The Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project database, the literature and, sparingly, expert opinion. One-way and probabilistic sensitivity analyses were undertaken, as well as subgroup analyses of patients over 65 years old and a population at greater risk of NSAID-related AEs.

Results In the base case the model estimated naproxen to be the lowest total-cost treatment, tapentadol the highest cost, and duloxetine the most effective after considering AEs. Duloxetine accumulated 0.027 discounted quality-adjusted life-years (QALYs) more than naproxen and 0.013 more than oxycodone. Celecoxib was dominated by naproxen, tramadol was subject to extended dominance, and strong opioids were dominated by duloxetine. The model estimated an incremental cost-effectiveness ratio (ICER) of US$47,678 per QALY for duloxetine versus naproxen. One-way sensitivity analysis identified the probabilities of NSAID-related cardiovascular AEs as the inputs to which the ICER was most sensitive when duloxetine was compared with an NS AID. When compared with a strong opioid, duloxetine dominated the opioid under nearly all sensitivity analysis scenarios. When compared with tramadol, the ICER was most sensitive to the costs of duloxetine and tramadol. In subgroup analysis, the cost per QALY for duloxetine versus naproxen fell to US$24,125 for patients over 65 years and to US$18,472 for a population at high risk of cardiovascular and gastrointestinal AEs.

Conclusion The model estimated that duloxetine was potentially cost effective in the base-case population and more cost effective for subgroups over 65 years or at high risk of NSAID-related AEs. In sensitivity analysis, duloxetine dominated all strong opioids in nearly all scenarios.

1 Background

Guidelines for the pharmacological treatment of osteoarthritis universally recommend acetaminophen as the first-line oral therapy of choice for mild to moderate osteoarthritis pain due to its safety and efficacy [1], Upon failure of acetaminophen (paracetamol) to provide pain relief, selective and non-selective nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for patients not at risk of associated cardiovascular and gastrointestinal adverse events (AEs). For patients in moderate to severe pain or at greater risk of cardiovascular or gastrointestinal AEs, opioids may be considered [2], The long-term use of NSAIDs and opioids among older patients, however, is not advised because of AEs, lack of efficacy or the potential, with opioids, for drug abuse [3, 4], At least one major guideline cautions that NS AID use should be at the lowest dose and shortest duration to control pain and warns that strong opioids should be used only in exceptional cases of severe pain [5],

Duloxetine is a serotonin and norepinephrine reuptake inhibitor that has antidepressant and pain-relieving properties [6], It has previously been indicated for diseases such as major depressive disorder, generalized anxiety disorder, diabetic peripheral neuropathic pain and fibromyalgia. …

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