Second Department of Internal Medicine, Osaka Medical College, 2-7 Digaku-cho, Takatsuki, Japan.
Unit of Public Health and Preventive Medicine, School of Medicine, Yokohama City University, Yokohama, Japan.
J Gastroenterol. 2019 Dec;54(12):1083-1095. doi: 10.1007/s00535-019-01609-2. Epub 2019 Aug 8.
Gastroesophageal reflux disease (GERD) can be treated using a vonoprazan-first strategy (first-line treatment with vonoprazan), or esomeprazole-first/rabeprazole-first strategies (first-line treatment with proton-pump inhibitors [PPIs], esomeprazole/rabeprazole, followed by a switch to vonoprazan). This cost-utility analysis used long-term simulation modeling to evaluate the cost-effectiveness of a vonoprazan-first strategy compared with the esomeprazole-first and rabeprazole-first strategies.
A Markov simulation model was developed to evaluate the cost-effectiveness of vonoprazan-first, esomeprazole-first, and rabeprazole-first strategies, comprising healing and maintenance therapies, over 5 years (4-week cycles). Healing therapy began with the administration of a normal dose of drug per real-world practice. If patients were not healed endoscopically, either a longer duration of healing therapy was provided (vonoprazan), the dose was increased (rabeprazole), or patients were switched to vonoprazan (immediately for esomeprazole, and after dose-escalation for rabeprazole, respectively). Healed patients received maintenance (lower/same dose as healing therapy). Recurrence resulted in re-challenge with healing therapy. Transition probabilities were derived from the results of indirect comparisons (network meta-analysis) and costs calculated from the Japanese payer perspective. Outcomes were defined as quality-adjusted life years (QALYs), with utilities based on published values.
Expected costs of the vonoprazan-, esomeprazole-, and rabeprazole-first strategies were ¥36,194, ¥76,719, and ¥41,105, respectively, over 5 years. QALY gains for vonoprazan-first strategy versus the esomeprazole- and rabeprazole-first strategies were 0.014 and 0.003, respectively. Both estimated incremental cost-effectiveness ratios were dominant and robust to two sensitivity analyses.
Vonoprazan-first strategy increased QALYs and appeared to be cost-effective for GERD patients compared with the esomeprazole- or rabeprazole-first strategies.
胃食管反流病（GERD）可以采用沃诺拉赞优先策略（一线治疗采用沃诺拉赞）或埃索美拉唑优先/雷贝拉唑优先策略（一线治疗采用质子泵抑制剂[PPIs]埃索美拉唑/雷贝拉唑，然后换用沃诺拉赞）进行治疗。本项成本效用分析采用长期模拟模型，评估与埃索美拉唑优先和雷贝拉唑优先策略相比，沃诺拉赞优先策略的成本效益。
采用 Markov 模拟模型，评估沃诺拉赞优先、埃索美拉唑优先和雷贝拉唑优先策略在 5 年内（4 周周期）的成本效益，涵盖愈合和维持治疗。愈合治疗从根据真实世界实践给予常规剂量药物开始。如果患者内镜下未愈合，则提供更长时间的愈合治疗（沃诺拉赞）、增加剂量（雷贝拉唑）或患者换用沃诺拉赞（埃索美拉唑立即换用，雷贝拉唑增加剂量后换用）。已愈合的患者接受维持治疗（与愈合治疗相同/较低剂量）。复发导致重新接受愈合治疗。转移概率源自间接比较（网络荟萃分析）的结果，成本则根据日本支付方视角进行计算。结果定义为质量调整生命年（QALY），采用已发表的效用值。
预计沃诺拉赞、埃索美拉唑和雷贝拉唑优先策略在 5 年内的成本分别为 36194 日元、76719 日元和 41105 日元。与埃索美拉唑优先和雷贝拉唑优先策略相比，沃诺拉赞优先策略的 QALY 增益分别为 0.014 和 0.003。两种估计的增量成本效益比均为优势且对两种敏感性分析稳健。
与埃索美拉唑或雷贝拉唑优先策略相比，沃诺拉赞优先策略增加了 QALY，并且似乎对 GERD 患者具有成本效益。
