A Model Based Cost-Effectiveness Analysis of Routine Genotyping for CYP2D6 among Older, Depressed Inpatients Starting Nortriptyline Pharmacotherapy

Abstract

ObjectiveGenotyping for CYP2D6 has the potential to predict differences in metabolism of nortriptyline. This information could optimize pharmacotherapy. We determined the costs and effects of routine genotyping for old aged Dutch depressed inpatients.MethodsWith a decision-tree, we modelled the first 12 weeks of nortriptyline therapy. Direct costs of genotyping, hospitalization, therapeutic drug monitoring and drugs were included. Based on genotype, patients could be correctly, sub-, or supratherapeutically dosed. Improvement from sub- or supratherapeutically dosed patients to correctly dosed patients was simulated, assuming that genotyping would prevent under- or overdosing of patients. In the base case, this improvement was assumed to be 35%. A probabilistic sensitivity analysis (PSA) was performed to determine uncertainty around the incremental cost-effectiveness ratio (ICER).ResultsIn the base case analysis, costs for genotyping were assumed €200 per test with a corresponding ICER at €1 333 000 per QALY. To reach a €50 000 per QALY cut-off, genotyping costs should be decreased towards €40 per test. At genotyping test costs < €35 per test, genotyping was dominant. At test costs of €17 per test there was a 95% probability that genotyping was cost-effective at €50 000 per QALY.ConclusionsCYP2D6 genotyping was not cost-effective at current genotyping costs at a €50 000 per QALY threshold, however at test costs below €40, genotyping could be costs-effective.

Economic evaluation in psychiatric pharmacogenomics: a systematic review

“…The QHES checklist can generate a score between 0 and 100, while a score of 75 and more is of the highest quality [40] (Supplemental Table 1). Three reviewers assessed the quality of all included studies [41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57][58] independently, when results differed (N = 3) though, the consensus was reached through discussion by all authors.…”

Pharmacogenetic testing for adverse drug reaction prevention: systematic review of economic evaluations and the appraisal of quality matters for clinical practice and implementation

“…Majority of the studies were conducted in European and American countries (43 studies) (73%), while studies related to HLA-B*58:01allopurinol and HLA-B*15:02-carbamazepine were mostly found in Asian countries. Most studies investigated the therapeutic area of cardiovascular diseases (24 studies) , followed by gout (8 studies) [40][41][42][43][44][45][46][47], human immunodeficiency virus (HIV) infection (8 studies) [48][49][50][51][52][53][54][55], autoimmune diseases (8 studies) [56][57][58][59][60][61][62][63], and epilepsy/neuropathic pain (6 studies) [64][65][66][67][68][69], cancer (3 studies) [70][71][72], major depressive disorder [73], and hormone replacement therapy [74].…”

“…CYP2D6 and nortriptyline-induced anticholinergic symptoms The CUA with model-based economic evaluation in the Netherland study showed that CYP2D6 screening for adjusting dose before starting nortriptyline compared to no screening would not be cost-effective since CYP2D6 was not potentially related to the reduction of ADRs and to the increased efficacy of nortriptyline in a major depressive disorder [73].…”

Protocol for a pharmacogenetic study of antidepressants: characterization of drug-metabolizing profiles of cytochromes CYP2D6 and CYP2C19 in a Sardinian population of patients with major depressive disorder

“…A recent review of the literature concluded that treatment decision making including the use of pharmacogenetic tests appears to be cost-effective or cost-saving for a high percentage of the drugs for which the FDA provided recommendations (Verbelen et al ., 2017). Most of the economic analysis concerning the use of pharmacogenetic tests in patients receiving antidepressants was done through the construction of pharmacoeconomic models that involved the simulation of patient cohorts for which costs and outcomes were estimated based on literature data and existing guidelines (Berm et al ., 2016). Furthermore, among the few available studies that included data collected on real patient cohorts, most were not conducted by independent researchers but by the companies that launched pharmacogenetic tools on the market (Bousman and Hopwood, 2016).…”