Smith K J, Roberts M S
Mercy Hospital of Pittsburgh, Pennsylvania, USA.
Pharmacoeconomics. 2000 Aug;18(2):95-104. doi: 10.2165/00019053-200018020-00001.
Antiviral treatment of herpes zoster is controversial because of uncertain benefits and relatively high costs. Most studies show that antiviral therapy lessens acute herpes zoster symptoms and postherpetic neuralgia (PHN). Current clinical recommendations support antiviral treatment of severely symptomatic herpes zoster in all adults, and mild herpes zoster in those 50 or 60 years of age or older. However, it is unclear if these recommended strategies are cost effective. Published studies of herpes zoster costs and the effect of antiviral therapy on costs and quality of life have significant variation in study design and results, as well as many shortcomings in the data. Thus, definitive economic recommendations cannot be made based on the present data. Another approach, which we have used, is to develop a 'reference case' analysis using decision-analysis techniques and the available data to estimate the incremental cost effectiveness of antiviral treatment in patients of differing age and herpes zoster severity. In the baseline analysis, parameter values and assumptions were consistently slightly biased against antiviral use. Effectiveness was measured in quality-adjusted life years (QALYs). We assumed that antiviral treatment did not change PHN risk, but decreased PHN duration in patients older than 50 years. PHN risk increased with age and with acute herpes zoster severity as seen in published data. Mild acute herpes zoster was assumed to have a utility value of 0.9 and severe acute herpes zoster a value of 0.7 on a scale where 0 = death and 1 = perfect health. Treating mildly symptomatic acute herpes zoster cost $US89,200/QALY gained in 40-year-olds, $US47,700/QALY in 60-year-olds and $US40,700/QALY in 70-year-olds (1995 values). Results were most sensitive to variation of antiviral costs (baseline $US134), but changes in acute symptom relief, PHN risk, duration, costs and utility, and antiviral effect on PHN duration increased costs/QALY above $US50,000 in 60- and 70-year-olds in extremes of parameter ranges. However, no variation resulted in treatment of mild illness in 40-year-olds to fall below $US50,000/QALY gained. Treatment of severe acute herpes zoster cost $US29,700, $US18,000 and $US16,500/QALY gained in 40-, 60- and 70-year-olds, respectively. Results were sensitive to variation of antiviral costs (> $US225) and acute symptom relief (< 21%) in 40-year-olds. Based on this analysis, antiviral therapy of herpes zoster seems economically justifiable for mildly symptomatic acute herpes zoster in patients aged 50 years and older, and for severely symptomatic acute herpes zoster in all adults.
由于益处不确定且成本相对较高，带状疱疹的抗病毒治疗存在争议。大多数研究表明，抗病毒治疗可减轻急性带状疱疹症状和带状疱疹后神经痛（PHN）。当前临床建议支持对所有成年患者的重度症状性带状疱疹以及50或60岁及以上患者的轻度带状疱疹进行抗病毒治疗。然而，这些推荐策略是否具有成本效益尚不清楚。已发表的关于带状疱疹成本以及抗病毒治疗对成本和生活质量影响的研究在研究设计和结果方面存在显著差异，数据也存在许多缺陷。因此，无法根据现有数据做出明确的经济建议。我们采用的另一种方法是使用决策分析技术和现有数据进行“参考案例”分析，以估计抗病毒治疗在不同年龄和带状疱疹严重程度患者中的增量成本效益。在基线分析中，参数值和假设始终略微不利于抗病毒治疗的使用。有效性以质量调整生命年（QALY）衡量。我们假设抗病毒治疗不会改变PHN风险，但会缩短50岁以上患者的PHN持续时间。如已发表数据所示，PHN风险随年龄和急性带状疱疹严重程度增加。轻度急性带状疱疹在0 = 死亡且1 = 完美健康的量表上的效用值假设为0.9，重度急性带状疱疹为0.7。治疗轻度症状性急性带状疱疹，40岁患者每获得一个QALY的成本为89,200美元，60岁患者为47,700美元，70岁患者为40,700美元（1995年价值）。结果对抗病毒治疗成本的变化最为敏感（基线为134美元），但急性症状缓解、PHN风险、持续时间、成本和效用的变化以及抗病毒治疗对PHN持续时间的影响在参数范围的极端情况下使60岁和70岁患者每QALY的成本增加到50,000美元以上。然而，没有任何变化会导致40岁患者轻度疾病治疗的每QALY成本降至50,000美元以下。治疗重度急性带状疱疹，40岁、60岁和70岁患者每获得一个QALY的成本分别为29,700美元、18,000美元和16,500美元。结果对40岁患者的抗病毒治疗成本变化（> 225美元）和急性症状缓解（< 21%）敏感。基于此分析，对于50岁及以上患者的轻度症状性急性带状疱疹以及所有成年患者的重度症状性急性带状疱疹，带状疱疹的抗病毒治疗在经济上似乎是合理的。
