Cryptococcal Meningitis Treatment Strategies Affected by the Explosive Cost of Flucytosine in the United States: A Cost-effectiveness Analysis
Cryptococcal Meningitis Treatment Strategies Affected by the Explosive Cost of Flucytosine in the United States: A Cost-effectiveness Analysis
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DOI：
10.1093/cid/ciw151
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发表时间：
2016-06-15
影响因子：
11.8
通讯作者：
Boulware, David R.
中科院分区：
文献类型：
--
作者：
Merry, Matthew;Boulware, David R.
背景在美国，隐球菌脑膜炎每年导致约3400例住院和约330例死亡。美国指南建议使用阿替霉素B+氟胞嘧啶治疗至少2周，然后使用氟康唑治疗至少8周。由于仿制药制造商的垄断，氟胞嘧啶目前在美国每天的费用约为2000美元，2周的氟胞嘧啶疗程费用约为28000美元。在英国，每日氟胞嘧啶治疗费用约为22美元。进行成本效益分析，以确定氟胞嘧啶相对于替代方案的价值。我们估计了3种隐球菌诱导方案的增量成本效果比（ICER）：（1）阿替霉素B脱氧胆酸盐治疗4周;（2）阿替霉素和氟胞嘧啶（100 mg/kg/d）治疗2周;（3）阿替霉素和氟康唑（800 mg/d）治疗2周。护理费用使用2015年美国价格和药物费用计算。生存率估计值来自随机试验，并与美国已发表的生存率数据进行比较。单药治疗的成本估计为83 227美元，单药治疗的成本估计为75 121美元，单药治疗的成本估计为44 605美元。阿替霉素加氟胞嘧啶的ICER为23 842美元/质量调整生命年。尽管近年来价格大幅上涨，但氟胞嘧啶目前在美国具有成本效益。联合使用阿替霉素和氟胞嘧啶是隐球菌脑膜炎最有吸引力的治疗策略，尽管价格上涨可能会造成获取问题，如果暴利趋势继续下去，这将加剧。
Background. In the United States, cryptococcal meningitis causes approximately 3400 hospitalizations and approximately 330 deaths annually. The US guidelines recommend treatment with amphotericin B plus flucytosine for at least 2 weeks, followed by fluconazole for a minimum of 8 weeks. Due to generic drug manufacturer monopolization, flucytosine currently costs approximately $2000 per day in the United States, with a 2-week flucytosine treatment course costing approximately $28 000. The daily flucytosine treatment cost in the United Kingdom is approximately $22. Cost-effectiveness analysis was performed to determine the value of flucytosine relative to alternative regimens.Methods. We estimated the incremental cost-effectiveness ratio (ICER) of 3 cryptococcal induction regimens: (1) amphotericin B deoxycholate for 4 weeks; (2) amphotericin and flucytosine (100 mg/kg/day) for 2 weeks; and (3) amphotericin and fluconazole (800 mg/day) for 2 weeks. Costs of care were calculated using 2015 US prices and the medication costs. Survival estimates were derived from a randomized trial and scaled relative to published US survival data.Results. Cost estimates were $83 227 for amphotericin monotherapy, $75 121 for amphotericin plus flucytosine, and $44 605 for amphotericin plus fluconazole. The ICER of amphotericin plus flucytosine was $23 842 per quality-adjusted life-year.Conclusions. Flucytosine is currently cost-effective in the United States despite a dramatic increase in price in recent years. Combination therapy with amphotericin and flucytosine is the most attractive treatment strategy for cryptococcal meningitis, though the rising price may be creating access issues that will exacerbate if the trend of profiteering continues.