Cost effectiveness of cladribine vs fingolimod in Portugal

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Firstly, this is not about money (I say this without a tell as my accountant taps away at their calculator nonchalantly). Really, this concept of cost-effectiveness is only obtrusive if you dislike politicking in any form or kind, or you’re British.

The easiest way to understand cost-effectiveness models in healthcare in my view is to understand the principles of bartering. In bartering money is not the commodity that is being discussed, but goods and services; which, in healthcare terms translates into something much bigger – life.

We may therefore at several levels want to couch this discussion in terms of cost-effectiveness models for the bean counters, but lets be clear that what we’re bartering for in fact is savings in health.

Treatment with cladribine tablets was associated with a delay in disease progression, resulting in a gain of 0.85 quality adjusted life years (QALYs*). From an economic viewpoint,this delay allowed for a decrease in total follow-up costs that amount to 25,935 € (time-horizon of 50 years).”

*one QALY = one year in perfect health.

Abstract

Cost-effectiveness of cladribine tablets versus fingolimod in patients with highly active relapsing multiple sclerosis in Portugal.

Pinheiro B, Guerreiro R, Costa J, Miguel LS.

Aims: To assess the cost-utility of cladribine tablets versus fingolimod in patients with highly active relapsing-remitting multiple sclerosis (RRMS) in Portugal.Methods: A 1-year cycle cohort-based Markov state transition model was developed to simulate disease progression, measured by Kurtzke Expanded Disability Status Scale (EDSS), relapses, and conversion to secondary-progressive MS (SPMS). Patients were assumed to remain on treatment until progression to EDSS level 7, conversion to SPMS, or complete loss of efficacy due to waning effect. Natural history was based on British Columbia Multiple Sclerosis registry, London Ontario database, UK MS Trust, and cladribine tablets clinical trial (CLARITY). Portuguese all-cause mortality was adjusted for the MS associated increased mortality. Clinical inputs for active treatments (disability progression and relapse rate) were estimated on a network meta-analysis. Utility weights were derived from UK-MS Survey and published literature. Resource consumption by EDSS and due to relapses was based on published literature, National DRG microdata and expert opinion. Unit costs were obtained from official sources. The analysis was conducted from payers’ perspective, time horizon of 50 years and discount rate of 5%, for both costs and benefits. Uncertainty was assessed via probabilistic and deterministic sensitivity analyses.Results: Compared to fingolimod, cladribine tablets were associated with a delay in progression, resulting in a gain of 0.85 quality adjusted life years (QALYs) and a cost decrease of 25.935 €. Probabilistic sensitivity analysis resulted in a mean ICER of -31,781€per QALY and was dominant in 98.7% of the simulations. Cladribine tablets were dominant across the scenario analyses tested.Conclusions: Treatment of highly active RRMS with cladribine tablets was less costly and more effective than treatment with fingolimod. Hence, it is a dominant strategy in the Portuguese setting. No conclusions can be drawn from the present study regarding other treatment options, in particular natalizumab and alemtuzumab.

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Neuro Doc Gnanapavan

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