Doull Iolo, Price David, Thomas Mike, Hawkins Neil, Stamuli Eugena, Tabberer Maggie, Gosden Toby, Rudge Helen
Children's Hospital for Wales, Cardiff, UK.
Curr Med Res Opin. 2007 May;23(5):1147-59. doi: 10.1185/030079907x187982.
To determine where in the treatment steps recommended by the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) Asthma Guideline it is cost-effective to use salmeterol xinafoate/fluticasone propionate combination inhaler (SFC) (Seretide) compared with other inhaled corticosteroid (ICS) containing regimens (with and without a long acting beta-2 agonist (LABA)) for chronic asthma in adults and children.
Meta-analyses of percentage symptom-free days (%SFD) were used within a cost-effectiveness model. Time spent in two asthma control health states, 'symptom-free' and 'with-symptoms' was used as the measure of differential treatment effectiveness. SFC was compared with varying doses of fluticasone propionate (FP) and beclometasone dipropionate (BDP) with or without a separate salmeterol inhaler, and with the budesonide/formoterol combination inhaler (BUD/FORM) (Symbicort). Drug costs, non-drug costs and quality adjusted life years (QALY) were incorporated into the analyses. Results are presented as cost per QALY ratios and uncertainty explored using probabilistic sensitivity analysis.
Compared with an increased dose of FP in adults, SFC either 'dominates' (i.e. cheaper and more effective) FP or the cost per QALY is 6852 pounds sterling. The cost per QALYs estimated in sensitivity analyses using BDP costs range from 5679 pounds sterling to 15,997 pounds sterling. For children the cost per QALY for SFC 50 Evohaler compared with an increased dose of FP is pound 15,739 pounds sterling. SFC is similarly clinically effective in improving %SFDs compared with FP plus salmeterol delivered in separate inhalers (mean differences for each dose comparison of -3.9 (low) (with a 95% confidence interval (CI): -12.96; 5.16); 4.10 (medium) (95% CI: -3.01; 11.21); -0.4 (high) (95% CI: -8.88; 8.08)) and BUD/FORM (mean difference of 0.40 (95% CI -3.69; 4.49)) in adults, and a cheaper SFC option is available at all doses (annual cost savings range from 18 pounds sterling-427 pounds sterling per patient). SFC was similarly effective compared with FP plus salmeterol in separate inhalers in children under 12 and also resulted in annual cost savings of between 47 pounds sterling and 77 pounds sterling. A number of other comparisons were also made and the results are available as electronic supplementary data.
This is the first analysis to estimate the cost-effectiveness of SFC in chronic asthma compared with multiple comparators and based on a systematic identification of relevant trials and data on %SFDs. The findings suggest that for adults and children uncontrolled on BDP 400 microg/day or equivalent it is a cost-effective option to switch to SFC (at an equivalent ICS dose) compared with increasing the dose of ICS. For adults and children aged 12 years and over who have passed this point and are uncontrolled on BDP 800 microg/day or equivalent, switching to SFC remains a cost-effective approach. Where an adult or child requires an ICS and a LABA to be co-prescribed, SFC is a cost-effective option compared with FP or BDP plus salmeterol delivered in separate inhalers. In adults who require combination therapy, SFC is a cost-effective option compared with BUD/FORM.
确定在英国胸科学会和苏格兰校际指南网络（BTS/SIGN）哮喘指南推荐的治疗步骤中，与其他含吸入性糖皮质激素（ICS）的治疗方案（联合或不联合长效β2受体激动剂（LABA））相比，使用昔萘酸沙美特罗/丙酸氟替卡松联合吸入器（SFC）（舒利迭）治疗成人和儿童慢性哮喘的成本效益如何。
在成本效益模型中对无症状天数百分比（%SFD）进行荟萃分析。将在两种哮喘控制健康状态“无症状”和“有症状”下所花费的时间用作差异治疗效果的衡量指标。将SFC与不同剂量的丙酸氟替卡松（FP）和二丙酸倍氯米松（BDP）进行比较，这些药物联合或不联合单独的沙美特罗吸入器，还与布地奈德/福莫特罗联合吸入器（BUD/FORM）（信必可都保）进行比较。分析中纳入了药物成本、非药物成本和质量调整生命年（QALY）。结果以每QALY成本比率呈现，并使用概率敏感性分析探索不确定性。
与成人增加剂量的FP相比，SFC要么“占优”（即更便宜且更有效），要么每QALY成本为6852英镑。使用BDP成本进行敏感性分析时，估计的每QALY成本范围为5679英镑至15997英镑。对于儿童，SFC 50吸乐吸与增加剂量的FP相比，每QALY成本为15739英镑。与单独吸入器中使用的FP加沙美特罗相比，SFC在改善%SFD方面临床效果相似（各剂量比较的平均差异为-3.9（低）（9月5%置信区间（CI）：-12.96；5.16）；4.10（中）（95%CI：-3.01；11.21）；-0.4（高）（95%CI：-8.88；8.08）），与BUD/FORM相比（平均差异为0.40（95%CI -3.69；4.49）），且在所有剂量下都有更便宜的SFC选项（每位患者每年节省成本范围为18英镑至427英镑）。与单独吸入器中使用的FP加沙美特罗相比，SFC在12岁以下儿童中同样有效，并且每年还可节省成本47英镑至77英镑。还进行了一些其他比较，结果可作为电子补充数据获取。
这是首次分析估计SFC与多种对照药物相比在慢性哮喘中的成本效益，并基于对相关试验和%SFD数据的系统识别。研究结果表明，对于每日使用400微克BDP或等效药物仍未得到控制的成人和儿童，与增加ICS剂量相比，改用SFC（等效ICS剂量）是一种具有成本效益的选择。对于已超过该剂量且每日使用800微克BDP或等效药物仍未得到控制的12岁及以上成人和儿童，改用SFC仍然是一种具有成本效益的方法。当成人或儿童需要联合使用ICS和LABA时，与单独吸入器中使用的FP或BDP加沙美特罗相比，SFC是一种具有成本效益的选择。对于需要联合治疗的成人，与BUD/FORM相比，SFC是一种具有成本效益的选择。
