Lifetime Cost-Effectiveness of Calcineurin Inhibitor Withdrawal After De Novo Renal Transplantation

Abstract

After renal transplantation, immunosuppressive regimens associated with high short-term survival rates are not necessarily associated with high long-term survival rates, suggesting that regimens may need to be optimized over time. Calcineurin inhibitor (CNI) withdrawal from a sirolimus-based immunosuppressive regimen may maximize the likelihood of long-term graft and patient survival by minimizing CNIassociated nephrotoxicity. In this study, a lifetime Markov model was created to compare the costeffectiveness of a sirolimus-based CNI withdrawl regimen (sirolimus plus steroids) with other common CNI-containing regimens in adult de novo renal transplantation patients. Long-term graft survival was estimated by renal function and data from published studies and the US transplant registry, including short-and long-term outcomes, utility weights, and health-state costs were incorporated. Drug costs were based on average daily consumption and wholesale acquisition costs. The model suggests that treatment with sirolimus plus steroids is more efficacious and less costly than regimens consisting of a CNI, mycophenolate mofetil, and steroids; therefore, CNI withdrawal not only shows potential for long-term clinical benefits but also is expected to be cost-saving over a patient's life compared with the most commonly prescribed CNI-containing regimens.

Immunosuppressive therapy for kidney transplantation in adults: a systematic review and economic model

“…One of the included studies compared immediate-release TAC with TAC-PR (this study is reviewed in section 1.2 of the company's submission). 321 Four studies compared TAC with CSA (three 309,319,320 of which met the criteria for inclusion in the review of section 1.2; the remaining study 100 was excluded from the review of section 1.2 because it measured costs only for medication) and seven studies [306][307][308]311,[351][352][353] examined SRL in CNI avoidance or minimisation strategies compared with TAC (four studies 307,308,311 included in the review of section 1.2) and three studies [351][352][353] that were excluded from it as a result of the country to which they apply.…”

“…Twelve economic evaluations were included in the review (published in 14 publications 65,306,[308][309][310][311][312][313][314][315][316][319][320][321] ). Update searches, conducted on 18 November 2014, yielded an additional six reports 42,307,318,324,325 on economic evaluations eligible for inclusion in the review.…”

“…Thirteen studies 65,[307][308][309][310]312,[314][315][316][317][318][319]321 were included in this review. Five were studies of induction regimens, 312,[314][315][316][317] three of which were studies of UK adults, [315][316][317] and 10 were studies of initial and maintenance immunosuppression, 65,[307][308][309][310]318,319,321 four of which were of UK adults.…”

“…Five were studies of induction regimens, 312,[314][315][316][317] three of which were studies of UK adults, [315][316][317] and 10 were studies of initial and maintenance immunosuppression, 65,[307][308][309][310]318,319,321 four of which were of UK adults. 65,309,310,318 In what follows, studies of induction regimens are reviewed before reviewing studies of initial and maintenance immunosuppressive regimens, by country setting (UK vs. other).…”

“…308,310,311 Applying a decision-analytic model extending over the lifetime of a 46-year-old first-transplant patient, it found that the regimen was the dominant treatment for the adult renal transplantation population in general. Its use resulted in 0.30 extra years of life relative to TAC-containing triple therapy and 0.06 extra years of life relative to triple therapy containing CSA.…”