Cost-Effectiveness Analysis of Patiromer and Spironolactone Therapy in Heart Failure Patients with Hyperkalemia

Abstract

Background and ObjectiveCertain patients with heart failure (HF) are unable to tolerate spironolactone therapy due to hyperkalemia. Patiromer is a novel agent used to treat hyperkalemia and has been shown to be efficacious, safe, and well-tolerated. The potential clinical outcomes and economic value of using patiromer and spironolactone in patients with HF unable to otherwise tolerate spironolactone due to hyperkalemia are unclear. The objective of this analysis was to model the potential pharmacoeconomic value of using patiromer and spironolactone in patients with a history of hyperkalemia that prevents them from utilizing spironolactone.MethodsWe performed a cost-effectiveness analysis of treatment with patiromer, spironolactone, and an angiotensin-converting enzyme inhibitor (ACEI) in patients with New York Heart Association (NYHA) class III–IV HF compared with ACEI alone. A Markov model was constructed to simulate a cohort of 65-year-old patients diagnosed with HF from the payer perspective across the lifetime horizon. Clinical inputs were derived from the RALES and OPAL-HK randomized trials of spironolactone and patiromer, respectively. Utility estimates and costs were derived from the literature and list prices. Outcomes assessed included hospitalization, life expectancy, and quality-adjusted life-years (QALYs), costs, and the incremental cost-effectiveness ratio (ICER). One-way and probability sensitivity analyses were performed to test the robustness of the model findings.ResultsTreatment with patiromer–spironolactone–ACEI was projected to increase longevity compared with ACEI alone (5.29 vs. 4.62 life-years gained, respectively), greater QALYs (2.79 vs. 2.60), and costs (US$28,200 vs. US$18,200), giving an ICER of US$52,700 per QALY gained. The ICERs ranged from US$40,000 to US$85,800 per QALY gained in 1-way sensitivity analyses.ConclusionOur results suggest that the use of spironolactone–patiromer–ACEI may provide clinical benefit and good economic value in patients with NYHA class III–IV HF unable to tolerate spironolactone due to hyperkalemia.Electronic supplementary materialThe online version of this article (10.1007/s40273-018-0709-3) contains supplementary material, which is available to authorized users.

Clinical Management of Hyperkalemia

“…Although such data are limited, costeffectiveness analysis from the US payer perspective found that the benefits of adding patiromer to treatment in patients with HF and hyperkalemia outweighed the incremental total costs, with lower hospitalization costs, improved survival, and increased quality of life. 97 Sodium Polystyrene Sulfonate. Sodium polystyrene sulfonate is a polymeric cation- exchange resin that binds K þ ions in exchange for sodium ions in the distal colon.…”

An indigestible resin

“…Le groupe traité par patiromer montre non seulement une réduction significative de lhyperkaliémie par rapport au groupe placebo mais cette diminution se traduit cliniquement par un moins grand nombre darrêt dun traitement par inhibiteur du RAS 13 . Toutefois, lengouement pour cette nouvelle molécule peut être pondéré par au moins deux aspects : son coût de 375,38 pour 30 sachets (quoique certains défendent léconomie engendrée par une qualité de vie et de survie sur un plus grand nombre de patients traités par inhibiteur du RAS, argument qui reste à démontrer par une étude prospective) et surtout par le fait quelle na pas été comparée directement au standard actuel, une résine échangeuse d ions classique 15 . CONCLUSION Aussi, au vu de la faible fréquence de la nécrose colique, prouver une plus grande tolérance du patiromer sur une résine classique nécessiterait une étude face à face de ces deux molécules avec plusieurs dizaines de milliers de participants à enrôler, ce qui ne se fera probablement jamais.…”

Economic Issues in Heart Failure in the United States

“…A single, industry-sponsored analysis found patiromer had an incremental cost-effectiveness ratio of $52,700/QALY. [48] This study made strong assumptions regarding the overall clinical impact of patiromer based on the OPAL-HK trial, a single-arm study of patients with hyperkalemia and chronic kidney disease (including non-heart failure patients) that demonstrated patiromer's potassium-lowering effect. [49] With limited effectiveness data, the economic value of patiromer remains uncertain.…”