Podrid P J, Kowey P R, Frishman W H, Arnold R J, Kaniecki D J, Beck J R, Beshansky J R
Cardiac Arrhythmia Service, University Hospital, Boston, Massachusetts 02118.
Am J Cardiol. 1991 Dec 15;68(17):1662-7. doi: 10.1016/0002-9149(91)90326-g.
Quinidine and procainamide have the potential for major organ toxicity, whereas mexiletine has been reported to have little risk of organ toxicity, serious proarrhythmia or congestive heart failure, but a relatively high incidence of nuisance side effects. In light of the potential adverse effects of all antiarrhythmic agents as highlighted by the Cardiac Arrhythmia Suppression Trial, the relative cost-effectiveness of these 3 agents was assessed. Based on a review of greater than 1,000 published reports, studies included in the analysis examined greater than or equal to 1 of these agents in adults, with adequate efficacy or safety data, or both. The majority of studies assessed patients with symptomatic or malignant arrhythmias, or both. Data were analyzed using a decision analysis/cost-effectiveness model. Probabilities were averaged using techniques of meta-analysis. Costs were obtained from a university medical center cost-accounting system and from expected follow-up visits to university clinics. Thirty-seven separate side effects were included in the analysis. In terms of overall cost, 12 months of mexiletine would engender $875, quinidine $1,239 and procainamide $1,911 of expenses. Mexiletine dominates the older agents in terms of cost per successful drug response, a result that holds over a wide range of efficacy and safety data. Analyses demonstrated no increase in all-cause mortality for quinidine and mexiletine over placebo, but a trend toward higher mortality with procainamide. The results suggest that mexiletine is a cost-saving alternative therapy for ventricular arrhythmias when adverse reactions are considered in addition to pharmaceutical costs and treatment efficacy.
奎尼丁和普鲁卡因胺具有导致主要器官毒性的可能性，而据报道美西律几乎没有器官毒性、严重心律失常或充血性心力衰竭的风险，但有较高发生率的烦扰性副作用。鉴于心律失常抑制试验所强调的所有抗心律失常药物的潜在不良反应，对这三种药物的相对成本效益进行了评估。基于对1000多篇已发表报告的回顾，纳入分析的研究考察了这三种药物中至少一种在成年人中的使用情况，且有足够的疗效或安全性数据，或两者皆有。大多数研究评估的是有症状性心律失常或恶性心律失常，或两者皆有的患者。使用决策分析/成本效益模型对数据进行分析。采用荟萃分析技术对概率进行平均。成本数据来自大学医学中心的成本核算系统以及大学诊所预期的随访就诊情况。分析中纳入了37种不同的副作用。在总体成本方面，使用12个月的美西律花费875美元，奎尼丁花费1239美元，普鲁卡因胺花费1911美元。就每次成功药物反应的成本而言，美西律优于较老的药物，这一结果在广泛的疗效和安全性数据范围内均成立。分析表明，奎尼丁和美西律相比安慰剂并未增加全因死亡率，但普鲁卡因胺有导致更高死亡率的趋势。结果表明，在考虑药物成本、治疗疗效以及不良反应的情况下，美西律是治疗室性心律失常的一种节省成本的替代疗法。
