Latour-Perez Jaime, de-Miguel-Balsa Eva
Intensive Care and Coronary Unit, Hospital General Universitario de Elche, Elche, Spain.
Pharmacoeconomics. 2009;27(7):585-95. doi: 10.2165/11310120-000000000-00000.
Fondaparinux has been shown to reduce the risk of major bleeding and 30-day mortality compared with enoxaparin, in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). However, its cost effectiveness is not well known.
To evaluate the effectiveness and economic attractiveness of fondaparinux relative to enoxaparin in patients with NSTE-ACS treated with triple antiplatelet therapy and early (non-urgent) invasive strategy.
The decision model compares two alternative strategies: subcutaneous (SC) enoxaparin (1 mg/kg 12 hourly) versus SC fondaparinux (2.5 mg/day) in NSTE-ACS patients pre-treated with triple antiplatelet therapy and early revascularization. Cost-effectiveness and cost-utility analyses were performed from a healthcare perspective, based on a Markov model with a time horizon of the patient lifespan. Univariate sensitivity analysis and probabilistic (Monte Carlo) microsimulation analysis were performed.
In the base-case analysis (65 years, Thrombolysis In Myocardial Infarction [TIMI] score 4), the use of fondaparinux was associated with a significant reduction in major bleeding, a slight reduction in adverse cardiac events, and minor improvements in survival and QALYs, together with a small reduction in costs. The dominance of fondaparinux over enoxaparin remained unchanged in the univariate sensitivity analyses. According to Monte Carlo simulation, fondaparinux was cost saving in 99.9% of cases.
Compared with enoxaparin, the use of fondaparinux in patients with NSTE-ACS managed with an early invasive strategy appears to be cost effective, even in patients with a low risk of bleeding.
在非ST段抬高型急性冠状动脉综合征（NSTE-ACS）患者中，与依诺肝素相比，磺达肝癸钠已被证明可降低大出血风险和30天死亡率。然而，其成本效益尚不清楚。
评估在接受三联抗血小板治疗和早期（非紧急）侵入性策略的NSTE-ACS患者中，磺达肝癸钠相对于依诺肝素的有效性和经济吸引力。
该决策模型比较了两种替代策略：在接受三联抗血小板治疗和早期血运重建的NSTE-ACS患者中，皮下注射（SC）依诺肝素（每12小时1 mg/kg）与皮下注射磺达肝癸钠（2.5 mg/天）。从医疗保健角度进行成本效益和成本效用分析，基于一个时间跨度为患者寿命的马尔可夫模型。进行了单变量敏感性分析和概率（蒙特卡洛）微观模拟分析。
在基础病例分析（65岁，心肌梗死溶栓[TIMI]评分为4）中，使用磺达肝癸钠与大出血显著减少、不良心脏事件略有减少、生存率和质量调整生命年（QALY）略有改善以及成本略有降低相关。在单变量敏感性分析中，磺达肝癸钠相对于依诺肝素的优势保持不变。根据蒙特卡洛模拟，磺达肝癸钠在99.9%的病例中节省成本。
与依诺肝素相比，在采用早期侵入性策略治疗的NSTE-ACS患者中使用磺达肝癸钠似乎具有成本效益，即使在出血风险较低的患者中也是如此。
