Mifepristone Combination Therapy Compared With Misoprostol Monotherapy for the Management of Miscarriage

Abstract

OBJECTIVE: To assess whether mifepristone pretreatment adversely affects the cost of medical management of miscarriage. METHODS: Decision tree analyses were constructed, and Monte Carlo simulations were run comparing costs of combination therapy (mifepristone and misoprostol) with monotherapy (misoprostol alone) for medical management of miscarriage in multiple scenarios weighing clinical practice, patient income, and surgical evacuation modalities for failed medical management. Rates of completed medical evacuation for each were obtained from a recent randomized controlled trial. RESULTS: In every scenario, combination therapy offered a significant cost advantage over monotherapy. Using a Monte Carlo analysis, cost differences favoring combination therapy ranged from 6.3% to 19.5% in patients making federal minimum wage. The cost savings associated with combination therapy were greatest in scenarios using a staged approach to misoprostol administration and in scenarios using in–operating room dilation and curettage as the only modality for uterine evacuation, a savings of $190.20 (99% CI 189.35–191.07) and $217.85 (99% CI 217.19–218.50) per patient in a low-income wage group, respectively. A smaller difference was seen in scenarios using in-office manual vacuum aspiration to complete medical management failures. As patients' wages increased, the difference in cost between combination therapy and monotherapy increased. CONCLUSION: Mifepristone combined with misoprostol is, overall, more cost effective than monotherapy, and therefore cost should not be a deterrent to its adoption in the management of miscarriage.

Economic evaluation of medical versus surgical strategies for first trimester therapeutic abortion

“…strongly verified that pretreatment with mifepristone followed by misoprostol offered a significant cost advantage over monotherapy and resulted in higher completion rate of pregnancy termination and shorter treatment time for medical management of miscarriage than treatment with misoprostol alone. [ 13 ] This result is consistent with what has been found by Hunter et al . They have demonstrated that statistical models showed a 61.3% chance that mifepristone plus misoprostol was more cost effective than surgical pregnancy termination, as well as a 90.8% chance that it was more cost effective than methotrexate plus misoprostol.…”

“…Five studies had been conducted in the United States. [ 7 9 13 14 26 ] Other studies conducted in Spain,[ 15 ] Malawi, Pakistan and Tanzania,[ 16 ] Uganda,[ 16 22 ] Netherlands,[ 17 20 ] Nigeria,[ 18 24 ] Ghana,[ 18 ] Mexico,[ 1 ] Canada,[ 19 ] South Africa,[ 21 ] Finland,[ 23 ] England,[ 25 ] Senegal,[ 27 ] and China. [ 28 ]…”

Economic evaluation of a randomized controlled trial comparing mifepristone and misoprostol with misoprostol alone in the treatment of early pregnancy loss

“…Nagendra et al also concluded that pre-treatment with mifepristone is the cost-effective alternative in case of EPL. This was also the conclusion of a secondary analysis of their data, in which Monte Carlo simulations were used to assess contribution of different expense categories [ 24 ]. An in-depth comparison between these two trials may be difficult as study design varies substantially, regarding medication regimen, applying expectant management prior to inclusion or prompt treatment and mean gestational age, which is approximately three weeks higher in our study.…”

Combination of Mifepristone and Misoprostol for First-Trimester Medical Abortion: A Comprehensive Review of the Literature

“…49 Overall, although mifepristone is a more expensive drug compared with misoprostol, the higher success rate of the combined regimen leads to reduced overall time spent on the process of abortion (time off work, office visits, need of surgical management for ongoing pregnancies), which in turn results in a significantly reduced cost. 22 It seems that the combination of mifepristone and misoprostol presents with advantages and is the criterion standard for first-trimester medical abortion, at least in high-income countries where mifepristone is available.…”

“…11 The finding that mifepristone can sensitize the myometrium to prostaglandins drove to the hypothesis that the combination of mifepristone and prostaglandins may provoke an enhanced effect on uterine contractions and, in turn, first-trimester medical abortion. 5,8,11,16,[18][19][20][21][22] Therefore, mifepristone could be used to prime the myometrium and cervix before the use of a prostaglandin, to improve the success rate of medical abortion. 4 A series of studies have since found a high effectiveness and acceptability of mifepristone combined with misoprostol, for first-trimester abortion, using various routes and dosages; however, the optimal approach remains undetermined.…”