A Model-Based Economic Evaluation of Cladribine Versus Alemtuzumab, Ocrelizumab and Natalizumab for the Treatment of Relapsing-Remitting Multiple Sclerosis with High Disease Activity in Chile

Abstract

The aim of this study was to evaluate the cost effectiveness of cladribine compared with alemtuzumab, natalizumab, and ocrelizumab for the treatment of highly active multiple sclerosis (HAD-MS) from the perspective of the Chilean health care public sector. Materials and Methods A Markov model was used to compare costs and quality-adjusted life-years (QALYs) over a 45-year time horizon using a 3% discount rate for costs and outcomes. Natural history of the disease was modeled in terms of progression of disability according to the Expanded Disability Status Scale (EDSS). A network meta-analysis was used as a source of comparative effectiveness for disability progression and annual relapse rates. Differences in costs and outcomes were modeled for only 10 years due to high temporal uncertainty. Ocrelizumab was assumed to have the same efficacy as cladribine due to lack of data. Direct costs were taken from national tariffs and expressed in 2019 US dollars. Utilities for EDSS health states were obtained from the literature. Second-order uncertainty was characterized through deterministic and probabilistic sensitivity analysis. Findings Compared with natalizumab (the current strategy covered in Chile), cladribine is associated with incremental costs and QALYs of US$70,989 and 1.875, respectively (incremental cost-effectiveness ratio [ICER] $37,861). Ocrelizumab was extendedly dominated by cladribine and natalizumab, and alemtuzumab was dominated by cladribine. A scenario analysis of a 10% discount did not modify the results substantially, but showed a decrease in the ICER of cladribine versus natalizumab (ICER $29,833/QALY). Implications Cladribine is a new oral alternative to treat patients with HAD-MS that is expected to produce higher QALYs than all evaluated alternatives. In the context of a conservative analysis, cladribine cannot be considered cost effective for the Chilean health care public sector using a 1 GDP per capita threshold. However, under reasonable discount scenarios, cladribine becomes an attractive alternative for the health system.

Cost-utility and cost-effectiveness analysis of disease-modifying drugs of relapsing–remitting multiple sclerosis: a systematic review

“…Of the included studies, twenty-four studies were carried out in European countries, seven in the United States, four in Canada, six in Iran, four in Saudi Arabia, one in Thailand, one in Colombia, one in Chile, and one in Lebanon. Thirteen studies conducted CEA using a Markov model [18,[22][23][24][25][26][27][28][29][30][31][32][33][34], eight studies conducted CUA using a Markov model [35][36][37][38][39][40][41][42], one study conducted CUA Were the perspective of the analysis (health system, third-party payer, etc.) and reason for its selection stated?…”

“…One study was conducted from the UK societal cost perspective [22], two from UK National Health Service [2,58], one from UK third-party payer perspective [55], two from Canadian healthcare system perspective [13,59], one from Chilean health care public sector perspective [38], one from Kingdom of Saudi Arabia payer's perspective [56], two from Payer perspective [34,45], one from the Colombian healthcare system perspective [57], one from Italian societal perspective [28], one from Italian National Healthcare System perspective [60], one study from Swiss health insurance perspective [30], one from Payer and societal perspective [17], eleven studies from societal perspective [19, 27, 29, 31-33, 35, 42-44, 51], three studies from Ministry of Health perspective [50,52,64], one from Third-party payer perspective [23], one from Saudi payer perspective [24], two from US payer perspective [18,37], one from US health care payer perspective [47], one from both National Health Service and Personal Social Services perspective [25], two from Spanish National Health System [39,61], one from thirdparty payer perspective [63], one from both patients and third-party payers perspective [26], one from healthcare perspective [36], one from public healthcare perspective [49], one from both National Health Service and Personal Social Services perspective [41], one from both thirdparty payer & Societal [46], and one from Finnish payer perspective and Scenario analysis with a societal perspective [10], one from both health economics and societal perspective…”

“…In three studies, in addition to these two forms of medications, the best supportive care (BSC) strategy [10,30] and symptom management [24] were included in cost-effectiveness analysis. Eight studies analyzed both oral and intravenous infusions DMDs of RRMS [32,38,40,44,54,55,57,58]. Ten studies analyzed all three types of DMDs of RRMS [13,19,23,33,34,37,49,53,56,64].…”

“…Commercial in confidence estimates of efficacy, the most favorable estimate is £35 000 per QALY and the least favorable is £104 000 per QALY --- tweleve studies compared DMDs in patients with highly active RRMS (HARRMS) [22,32,34,38,39,41,44,45,[54][55][56][57]61].…”

Cladribine Tablets for Relapsing–Remitting Multiple Sclerosis: A Clinician’s Review

“…A simulation model assessing the efficiency of cladribine tablets or DMTs delivered by infusion from a facility perspective in the UK found that cladribine tablets could decrease the burden of hospital-based administration and monitoring [ 78 ]. However, the cost of DMTs is an important driver in many cost-assessment models, and cladribine tablets has been found to be cost effective compared to alternative treatments in modeling based on use in many country-specific settings, including Finland [ 79 ], Portugal [ 80 ], Spain [ 81 ], Saudi Arabia [ 82 ], Chile [ 83 ], Iran [ 84 ], and Poland [ 85 ].…”