Collins Curtis D, Stuntebeck Emily R, DePestel Daryl D, Stevenson James G
Department of Pharmacy Services, University of Michigan Health System, Ann Arbor, MI 48109-0008, USA.
Clin Drug Investig. 2007;27(4):233-41. doi: 10.2165/00044011-200727040-00002.
Liposomal amphotericin B (LAmB) has demonstrated similar efficacy to conventional amphotericin B for antifungal treatment in patients with febrile neutropenia; however, it is not without toxicities and is associated with a high acquisition cost. Despite this high cost, LAmB has been shown to have a pharmacoeconomic advantage over less expensive agents. Voriconazole is a potential alternative for empirical antifungal treatment of febrile neutropenia. The objective of this study was to assess the economic outcomes of voriconazole versus LAmB in patients with fever and neutropenia.
A decision analytical model was developed from a hospital perspective based on a 2-year (2002-2003) review of outcomes and prescribing practices in febrile neutropenic patients at a tertiary care medical centre. Literature reports and expert opinion were used to further populate the model. Sensitivity analyses and Monte Carlo simulation enhanced the robustness of the model through variation of all probabilities and costs that populated the model.
Sixty-three cases were evaluated in the retrospective review. Thirty-two were initially given voriconazole and 31 were given LAmB. Patient demographic data were similar in each group. In the base case, patients initially given voriconazole displayed a 27% reduction in overall treatment cost over patients initially given LAmB (14,950 vs 20,591 $US). Sensitivity analysis determined that the cost advantage in the voriconazole arm was maintained over a wide range of costs and probabilities. Variance in the cost of nephrotoxicity and medication cost did not significantly alter results. Monte Carlo simulation determined the voriconazole arm to be the optimal path in 65% of cases.
The decision model indicated that use of voriconazole as the preferred antifungal agent in adult haematology patients with febrile neutropenia should result in lower overall treatment costs relative to LAmB.
脂质体两性霉素B（LAmB）在发热性中性粒细胞减少症患者的抗真菌治疗中已显示出与传统两性霉素B相似的疗效；然而，它并非没有毒性，且购置成本高昂。尽管成本高昂，但LAmB已被证明相对于成本较低的药物具有药物经济学优势。伏立康唑是发热性中性粒细胞减少症经验性抗真菌治疗的一种潜在替代药物。本研究的目的是评估伏立康唑与LAmB在发热和中性粒细胞减少症患者中的经济效果。
基于对一家三级医疗中心发热性中性粒细胞减少症患者2年（2002 - 2003年）的结局和处方实践回顾，从医院角度建立了一个决策分析模型。文献报告和专家意见被用于进一步完善该模型。敏感性分析和蒙特卡洛模拟通过改变构成模型的所有概率和成本来增强模型的稳健性。
回顾性分析中评估了63例病例。32例最初给予伏立康唑，31例给予LAmB。每组患者的人口统计学数据相似。在基础病例中，最初给予伏立康唑的患者总体治疗成本比最初给予LAmB的患者降低了27%（分别为14,950美元和20,591美元）。敏感性分析确定，在广泛的成本和概率范围内，伏立康唑组的成本优势得以维持。肾毒性成本和药物成本的变化并未显著改变结果。蒙特卡洛模拟确定伏立康唑组在65%的病例中为最佳治疗路径。
决策模型表明，在成年血液学发热性中性粒细胞减少症患者中，使用伏立康唑作为首选抗真菌药物相对于LAmB应能降低总体治疗成本。
