Which First-Line Treatments Are Most Cost-Effective?

TOPLINE:

For initial treatment of eosinophilic esophagitis (EoE), an elimination diet is the most cost-effective option from a payer perspective and proton pump inhibitor (PPI) therapy is more cost-effective from a societal perspective, while dupilumab would require substantial price reductions to be cost-effective, a new study suggests.

METHODOLOGY:

• Researchers constructed Markov models to evaluate cost-effectiveness from payer and societal perspectives of three first-line treatments for EoE: PPI therapy (20 mg omeprazole twice daily); swallowed topical corticosteroids (tCS, 1 mg budesonide twice daily); and six-food (SFED), four-food (FFED) and two-food (2FED) elimination diets.
• A separate, simplified model compared the biologic dupilumab to PPI and tCS.
• The primary outcome was the incremental cost-effectiveness ratio (ICER) at 2- and 5-year time horizons. Treatment strategies with an ICER less than the willingness-to-pay threshold of $100,000 per quality-adjusted life year was considered cost-effective.

TAKEAWAY:

• In the 5-year time horizon, the average costs were lowest for SFED ($15,296.81), followed by PPIs ($16,153.77) and tCS ($20,975.33). The 2-year time horizon yielded costs of $7542.42 for PPI, $8307.61 for SFED, and $9720.91 for tCS.
• As initial treatment, elimination diets offered the highest efficacy and lowest cost from a payer’s perspective and were favored in models projected to 2 and 5 years, with the exception of 2FED at 2 years.
• Conversely, pharmacologic therapy was preferred from the societal perspective, in which patient-specific costs, such as travel, excess dietary expenses, and lost work, were included.
• A comparison of pharmacologic strategies, conducted due to many patients’ intolerance of elimination diets, found that PPI therapy was favored due to a combination of significantly lower cost and moderate efficacy, as well as the high cost per additional unit of effectiveness of tCS.
• The quarterly cost of dupilumab would have to drop from $7311 to $2038.50 for the biologic to be cost effective relative to tCS and to $302.55 to be cost effective relative to PPI therapy, according to price threshold analyses.

IN PRACTICE:

“While our study indicates that elimination diets may be the most cost-effective initial strategy from the payers’ perspective, it may carry significant burden from the patients’ standpoint, including the need for frequent endoscopy during food re-introduction, impact on quality of life on a more restrictive diet, and the long-term cost of the diet. The choice of initial therapy for EoE in the clinical setting should, therefore, continue to take into account all factors including costs and patient preference,” the researchers wrote. “Nevertheless, cost-effective clinical pathways for health systems may prioritize elimination diet therapy, with preference for FFED in the short-medium term [1-2 years] or SFED in the long term [5 years]. If pharmacotherapy is preferred, our study suggests that PPI would be the more cost-effective initial strategy, followed by steroids and subsequently dupilumab.”

SOURCE:

The study, with first author Brent Hiramoto, MD, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, was published online in the American Journal of Gastroenterology.

LIMITATIONS:

The study relied on observational data for PPI and SFED response rates, which may introduce uncertainty. Indirect societal costs related to lost compensation and/or productivity from work and indirect expenditures related to travel and obtaining care were not modeled. The models incorporated crossover to second- and third-line therapies, which assumed consistent treatment responses.

DISCLOSURES:

The study had no commercial funding. One author served on advisory boards for Phathom Pharmaceuticals, Sanofi Pharmaceuticals, and Regeneron Pharmaceuticals. No other authors had any disclosures.