Plosker Greg L, Keam Susan J
Wolters Kluwer Health, Adis, Auckland, New Zealand.
Pharmacoeconomics. 2006;24(12):1249-72. doi: 10.2165/00019053-200624120-00008.
The addition of candesartan cilexetil (Atacand, Amias, Blopress, Kenzen, Ratacand) to standard therapy for chronic heart failure (CHF) provided important clinical benefits at little or no additional cost in France, Germany and the UK, according to a detailed economic analysis focusing on major cardiovascular events and prospectively collected resource-use data from the CHARM-Added and CHARM-Alternative trials in patients with CHF and left ventricular (LV) systolic dysfunction. Results of a corresponding cost-effectiveness analysis showed that candesartan cilexetil was either dominant over placebo or was associated with small incremental costs per life-year gained, depending on the country and whether individual trial or pooled data were used. Preliminary data from a US cost-effectiveness analysis based on CHARM data also showed favourable results for candesartan cilexetil. Two cost-effectiveness analyses of candesartan cilexetil in hypertension have been published, both conducted in Sweden. Data from the SCOPE trial in elderly patients with hypertension, which showed a significant reduction in nonfatal stroke with candesartan cilexetil-based therapy versus non-candesartan cilexetil-based treatment, were incorporated into a Markov model and an incremental cost-effectiveness ratio of euro12 824 per QALY gained was calculated (2001 value). Another modelled cost-effectiveness analysis of candesartan cilexetil was based on the ALPINE trial, in which the incidence of new-onset diabetes was significantly lower in patients with newly diagnosed hypertension who were randomised to candesartan cilexetil (with or without felodipine) than among those who received hydrochlorothiazide (with or without atenolol). Although candesartan cilexetil was dominant over hydrochlorothiazide, the ALPINE cost-effectiveness analysis relied on a small number of clinical events and did not evaluate the incremental cost of candesartan cilexetil per life-year or QALY gained. In conclusion, despite some inherent limitations, economic analyses incorporating CHARM data and conducted primarily in Europe have shown that candesartan cilexetil appears to be cost effective when added to standard CHF treatment in patients with CHF and compromised LV systolic function. The use of candesartan cilexetil as part of antihypertensive therapy in elderly patients with elevated blood pressure was also deemed to be cost effective in a Swedish analysis, primarily resulting from a reduced risk of nonfatal stroke (as shown in the SCOPE study); however, the generalisability of results to other contexts has not been established. Cost-effectiveness analyses comparing candesartan cilexetil with ACE inhibitors or other angiotensin receptor blockers in CHF or hypertension are lacking, and results reported for candesartan cilexetil in a Swedish economic analysis of ALPINE data focusing on outcomes for diabetes require confirmation and extension.
一项针对慢性心力衰竭（CHF）患者主要心血管事件的详细经济分析，以及从CHARM-Added和CHARM-Alternative试验中前瞻性收集的资源使用数据表明，在法国、德国和英国，在标准疗法基础上加用坎地沙坦酯（Atacand、Amias、Blopress、Kenzen、Ratacand）治疗慢性心力衰竭，几乎无需额外成本即可带来重要的临床益处，这些试验针对的是患有CHF和左心室（LV）收缩功能障碍的患者。相应的成本效益分析结果显示，根据国家以及使用的是单个试验数据还是汇总数据，坎地沙坦酯相对于安慰剂具有优势，或者每获得一个生命年仅产生少量增量成本。基于CHARM数据的美国成本效益分析的初步数据也显示坎地沙坦酯具有良好效果。已发表两项关于坎地沙坦酯治疗高血压的成本效益分析，均在瑞典进行。老年高血压患者SCOPE试验的数据显示，与非坎地沙坦酯治疗相比，基于坎地沙坦酯的治疗可显著降低非致死性卒中发生率，这些数据被纳入马尔可夫模型，并计算出每获得一个质量调整生命年（QALY）的增量成本效益比为12,824欧元（2001年价值）。另一项坎地沙坦酯的模型成本效益分析基于ALPINE试验，在该试验中，新诊断高血压患者被随机分配接受坎地沙坦酯（加或不加非洛地平）治疗，其新发糖尿病的发生率显著低于接受氢氯噻嗪（加或不加阿替洛尔）治疗的患者。尽管坎地沙坦酯相对于氢氯噻嗪具有优势，但ALPINE成本效益分析依赖于少量临床事件，且未评估坎地沙坦酯每生命年或每获得一个QALY的增量成本。总之，尽管存在一些固有局限性，但纳入CHARM数据且主要在欧洲进行的经济分析表明，对于CHF且LV收缩功能受损的患者，在标准CHF治疗基础上加用坎地沙坦酯似乎具有成本效益。在瑞典的一项分析中，坎地沙坦酯作为老年高血压患者降压治疗的一部分也被认为具有成本效益，这主要是由于非致死性卒中风险降低（如SCOPE研究所示）；然而，这些结果在其他情况下的可推广性尚未确定。缺乏在CHF或高血压患者中比较坎地沙坦酯与ACE抑制剂或其他血管紧张素受体阻滞剂的成本效益分析，并且在瑞典一项侧重于糖尿病结局的ALPINE数据分析中报告的坎地沙坦酯结果需要确认和扩展。
