Background There have been few published comparisons of various treatment options for acute gout flares that incorporate costs, newer dosing recommendations of colchicine and, of evolving biologic therapies.
Objectives To assess the relative effectiveness, toxicity, costs, and cost-effectiveness of 4 treatment classes for acute gout: non-steroidal anti-inflammatory drugs (NSAIDS), branded colchicine, systemic (oral and parenteral) corticosteroids and biologics.
Methods We modeled gout flares in adults (age 45 to 60 years) with no contraindications to any therapies using a decision tree model that incorporated quality of life impacts of the flare, and costs and health effects of adverse drug-related events. Probabilities of response to therapies, adverse events, health state utilities, and costs were informed by the literature, US hospital statistics, and by payment algorithms that may be employed by a typical third party payer. We utilized published data for canakinumab (Ilaris®, Novartis) as representative of biologic therapies, although this drug is not yet approved for use for gout. Outcomes and costs in US dollars were computed for a one year post-flare period. Incremental cost effectiveness ratios and cost effectiveness were measured in quality adjusted life days and years (QALD, QALY) gained.
Results Literature review suggested relatively small differences in overall effectiveness between treatments, in spite of a wide range of costs. Base-case analysis demonstrated that biologic therapy had the largest treatment effect (1.3 QALD) and corticosteroids had the smallest (0.82 QALD), compared to no treatment. However, treatment with corticosteroids cost only $2920 per QALY gained compared to no treatment. Colchicine and biologic cost much more for their incremental increase in health benefits at $50,735 per QALY, and over $16 million per QALY, respectively. After accounting for toxicity, all NSAIDs were less effective and more expensive than systemic steroids. Results were sensitive to a number of factors including health state utilities, flare duration and probabilities of response to steroid and to NSAID in the first 24 hours of use. Importantly, the cost of colchicine influenced the results of the analysis.
Conclusions When priced as an unbranded product, colchicine is cost effective for the treatment of acute gout flare. In the US, where colchicine is sold as a branded product, systemic corticosteroids provide a more cost effective alternative. At current prices, biologic therapy does not provide additional benefits commensurate with the cost.
Limitations These results apply to patients with gout who do not have absolute contraindications to any of the treatment options, such as allergies to the drugs, advanced liver or renal disease, or heart failure. Our models did not take into account the drug half-life of parenteral corticosteroids. Our assessment of biologic therapy may not be applicable to non-canakinumab therapies currently in development.
Disclosure of Interest K. Reiter: None Declared, E. Krishnan Grant/Research support from: Takeda, Consultant for: Takeda, Employee of: Stanford University, J. Goldhaber-Fiebert: None Declared
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.