A cost-effectiveness analysis of off-label atypical antipsychotic treatment in children and adolescents with ADHD who have failed stimulant therapy

Abstract

The objectives of this study are: (1) to estimate the expected health outcomes of atypical antipsychotics (AAPs) and other non-stimulant attention-deficit/hyperactivity disorder (ADHD) medications and (2) to evaluate the cost-effectiveness of AAPs compared to other non-stimulant ADHD medications. We used decision analysis to compare three alternatives for treating children and adolescents with ADHD who failed initial stimulant treatment: (1) AAPs, (2) a selective norepinephrine reuptake inhibitor (atomoxetine), and (3) selective α2-adrenergic agonists (clonidine and guanfacine). Probability estimates and quality-adjusted life year (QALY) weights were derived from a literature review. Cost-effectiveness was estimated using the expected health outcomes derived from the decision analysis and expected costs from the literature. The study was conducted from the third-party payer perspective, and the study period was 1 year. One-way deterministic sensitivity analysis and a Monte Carlo simulation were performed. Over the course of 1 year of ADHD pharmacotherapy, the highest QALY was for clonidine/guanfacine (expected QALY = 0.95) followed by atomoxetine (expected QALY = 0.94). Atypical antipsychotics yielded the lowest health outcome with an expected QALY of 0.84. In the cost-effectiveness analysis, the AAP strategy was dominated as it was less effective and more costly than other two strategies. Compared to clonidine/guanfacine, AAPs provided lower QALYs (0.11 QALY lost) at an additional cost of $2186 on average. Compared to atomoxetine, AAPs resulted in 0.10 QALYs lost at an additional cost of $2186. In this decision analysis model, AAPs provide lower expected health outcomes than other ADHD medications in children and adolescents who failed prior stimulant therapy. Furthermore, AAPs were not a cost-effective option.

The cost-effectiveness of treatments for attention deficit-hyperactivity disorder and autism spectrum disorder in children and adolescents: a systematic review

“…Most studies targeting ADHD were of good quality (n = 8) [32][33][34][35][36][37][38][39], and two studies were of moderate quality [40,41]. Both studies targeting ASD were of good quality [42,43].…”

“…Two investigated the added value of non-stimulant therapy (GXR-ER) adjunctive to stimulant therapy compared to stimulant monotherapy [36,39]. One study compared non-stimulant medications (LDX) to atomoxetine (ATX) [33]; and one study compared AAPs (aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, and ziprasidone) with other non-stimulant medications (ATX and clonidine/guanfacine) [34]. Among the moderate-quality studies, one study evaluated a psychosocial program including parent, teacher and child components and compared it to the same program with a parent-only component and to treatment-as-usual (TAU), which consisted of conventional treatment by community providers [40]; and one study compared non-stimulant medication (GXR-ER) to atomoxetine (ATX) [43].…”

“…Among the good-quality studies, seven were modeling exercises [33][34][35][36][37][38][39] and simulated the costs and benefits of pharmacotherapies over different time horizons. Four of these studies had a time horizon of 1 year [33,34,36,39], and three had time horizons between 6 and 12 years [35,37,38]. One study was an RCT with a time horizon of 6 months [32].…”

“…Three studies included utilities derived using direct methods from the general public (TTO or a visual analogue scale (VAS)) [36,38,39]. One study estimated QALYs based on All costs converted to 2020 US$ from original currency using a conversion rate based on Purchasing Power Parities (PPP) for gross domestic product from http://eppi.ioe.ac.uk/costc onver sion/ defau lt.aspx b A DFLY was defined as a year of life with a similar level of independence as a typically developing individual If more than one perspective, the broadest perspective was indicated Table 3 (continued) utilities sourced from the literature [34]. One study [32] conducted a CMA, and used mean scores on a validated measure of ADHD symptoms, the SNAP-IV (Swanson, Nolan, and Pelham Questionnaire) [44], as the outcome.…”

Treatment Patterns, Health Care Resource Utilization, and Health Care Cost Associated with Atypical Antipsychotics or Guanfacine Extended Release in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder in Quebec, Canada

“…In another U.S. study comparing the cost-effectiveness of AAPs, clonidine ER or GXR, and ATX in children and adolescents with ADHD who had failed stimulant treatment, clonidine ER or GXR was the most cost-effective strategy (C$4997.89/quality-adjusted life-years [QALY]), whereas AAPs were the least cost-effective (C$8254.76/QALY); ATX was associated with a cost of C$5051.06/QALY (Sohn et al 2016b).…”