Quantify Research, Stockholm, Sweden.
Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.
Osteoporos Int. 2024 Dec;35(12):2183-2193. doi: 10.1007/s00198-024-07251-w. Epub 2024 Oct 4.
Sequential romosozumab-to-alendronate or sequential teriparatide-to-alendronate can be a cost-effective treatment option for postmenopausal women at very high risk of fracture.
To estimate the 10-year probability of a major osteoporotic fracture (MOF) at which sequential treatment with romosozumab or teriparatide followed by alendronate, compared with alendronate alone, becomes cost-effective in a UK setting.
A microsimulation model with a Markov structure was used to simulate fractures, costs, and quality-adjusted life years (QALYs), in women receiving sequential treatment with either romosozumab or teriparatide followed by alendronate, compared with alendronate alone. Patients aged 50 to 90 years with a recent MOF, hip or spine fracture were followed from the start of a 5-year treatment until the age of 100 years or death. The analysis had a healthcare perspective. Efficacy of romosozumab, teriparatide and alendronate was derived from phase III randomised controlled trials. Resource use and unit costs were derived from the literature. Cost-effectiveness intervention threshold (CEIT), defined as the 10-year probability of a major osteoporotic fracture at which treatment becomes cost-effective, was compared with clinically appropriate intervention thresholds for bone-forming treatment in women with very high fracture risk as recommended by the UK National Osteoporosis Guideline Group (NOGG).
The base case analysis showed that sequential romosozumab-to-alendronate treatment was cost-effective from a 10-year MOF probability of 18-35% and above depending on age and site of sentinel fracture at a willingness to pay (WTP) of £30,000. For teriparatide-to-alendronate, treatment was cost-effective at a 10-year MOF probability of 27-57%. The results were sensitive to pricing of the drugs but relatively insensitive to treatment duration, romosozumab persistence assumptions, and site of sentinel fracture. The CEITs for romosozumab-to-alendronate treatment were lower than the clinical thresholds from the age of 70 years meaning that treatment could be considered both cost-effective and aligned with the NOGG treatment guidelines. By contrast, for teriparatide-to-alendronate the CEITs were higher than the clinical thresholds irrespective of age. However, cost-effective scenarios were found in the presence of strong clinical risk factors in addition to a recent sentinel fracture.
The results of this study indicate that sequential romosozumab-to-alendronate or teriparatide-to-alendronate treatment can be a cost-effective treatment option for postmenopausal women at very high risk of fracture.
估计 10 年内发生主要骨质疏松性骨折（MOF）的概率，在英国，与单独使用阿仑膦酸盐相比，使用罗莫佐单抗或特立帕肽序贯治疗，然后再用阿仑膦酸盐治疗，在何种情况下成为具有成本效益的治疗选择。
使用具有马尔可夫结构的微模拟模型来模拟骨折、成本和质量调整生命年（QALY），在接受罗莫佐单抗或特立帕肽序贯治疗后再用阿仑膦酸盐治疗的女性，与单独使用阿仑膦酸盐治疗的女性相比。年龄在 50 至 90 岁之间、最近发生过 MOF、髋部或脊柱骨折的患者，从开始 5 年的治疗到 100 岁或死亡时进行随访。分析采用医疗保健视角。罗莫佐单抗、特立帕肽和阿仑膦酸盐的疗效来自 III 期随机对照试验。资源使用和单位成本来自文献。成本效益干预阈值（CEIT），定义为治疗变得具有成本效益的 10 年内发生主要骨质疏松性骨折的概率，与英国国家骨质疏松症指南组（NOGG）推荐的用于治疗高骨折风险女性的骨形成治疗的临床适宜干预阈值进行了比较。
在基线情况下，罗莫佐单抗序贯治疗的成本效益，取决于年龄和哨兵骨折部位，在愿意支付（WTP）30000 英镑的情况下，10 年 MOF 概率为 18-35%及以上。特立帕肽序贯治疗的成本效益，在 10 年 MOF 概率为 27-57%时达到。结果对药物定价敏感，但对治疗持续时间、罗莫佐单抗持久性假设和哨兵骨折部位相对不敏感。与临床阈值相比，罗莫佐单抗序贯治疗的 CEIT 较低，这意味着该治疗既具有成本效益，又符合 NOGG 治疗指南。相比之下，对于特立帕肽序贯治疗，无论年龄大小，CEIT 均高于临床阈值。然而，在存在除近期哨兵骨折以外的强烈临床危险因素的情况下，也可以找到具有成本效益的方案。
这项研究的结果表明，对于骨折风险极高的绝经后妇女，罗莫佐单抗序贯治疗联合阿仑膦酸盐或特立帕肽序贯治疗联合阿仑膦酸盐治疗可能是一种具有成本效益的治疗选择。
