Cost-Effectiveness of Antifungal Supplementation of Corneal Cold Storage Media

Abstract

Purpose: To evaluate the cost-effectiveness of supplementing hypothermic cold storage media (CSM) with antifungal therapy.Design: Cost-effectiveness analysis (CEA). Participant: Base case of a patient with Fuch's endothelial dystrophy undergoing a first eye keratoplasty. Methods: Cost-effective analysis of the base case with corneal tissue stored in CSM or CSM supplemented with antifungal therapy over a 16-year time horizon. Multiple clinical scenarios were considered, including endothelial keratoplasty (EK) and penetrating keratoplasty (PK); amphotericin B, voriconazole, caspofungin, and combination therapy; and third-party payer and societal perspectives. The incidences were derived from PubMed literature searches and average wholesale prices of medications; all costs were discounted 3% per annum and adjusted for inflation to 2019 US dollars.Main Outcome Measures: Incremental cost-effectiveness ratios (ICERs).Results: In the reference case, a corneal endothelial graft stored in amphotericin Besupplemented CSM was the most cost-effective approach from a third-party payer and societal perspective. Probability sensitivity analysis (PSA) of the societal model for the EK was robust, with 93.5% being below an arbitrary willingness-to-pay threshold (WTP) of $20 000 per fungal infection averted. Voriconazole, caspofungin, and combination antifungals were less cost-effective than amphotericin B. The main factors influencing the CEA were the incidences of postkeratoplasty fungal infections, potential increases in graft failures, and antifungal costs. For grafts intended for PKs, antifungal supplementation was less cost-effective than for EKs.Conclusions: Antifungal supplementation with amphotericin B for EK grafts was the most cost-effective approach of the studied antifungals; however, the CEA was sensitive to potential changes in graft failure rates, underlining the importance of long-term safety studies. For full-thickness corneal grafts, antifungal supplementation was less cost-effective.

Efficacy of voriconazole and amphotericin B in corneal preservative media

“…Gibbons et al . [ 28 ] have studied the cost-effective analysis of supplementing hypothermic cold storage media with antifungal drugs. Amphotericin B was found to be more cost-effective than voriconazole, caspofungin, and a combination antifungals, especially for endothelial keratoplasty grafts.…”

Overview of Short-Term and Intermediate-Term Corneal Storage Solution: Comparison of Clinical Outcomes and Need For Future Research

“…To address the stability of antifungals in tissue storage solution, a dissolvable amphotericin B tablet Kerasave (AL.CHI.MI.A.S.R.L., Ponte San Nicolò, Italy) has shown promise with improved biocompatibility, prolonged shelf life, and efficacy against Candida. 14,66 Owing to the increasing incidence of postkeratoplasty infections, an analysis of the cost-effectiveness of antifungal supplementation of corneal tissue storage solution was considered, 67 including a variety of antifungal supplements such as amphotericin B, voriconazole, caspofungin, and combination therapy. A probabilistic sensitivity analysis found 18.1% of iterations were cost-effective from a third-party perspective compared with 15.2% from a societal perspective with $20,000 per event willingness to pay.…”

Posterior Segment Complications of Endothelial Keratoplasty

“…[38][39][40][41] Gibbons et al and Chiang et al evaluated the cost-effectiveness of antifungal supplementation and found that amphotericin B supplementation could be cost-effective in reducing the risk of fungal infections with endothelial grafts. 42,43 However, the hypothermic conditions may affect the pharmacokinetics of amphotericin. 16 A recent publication evaluated the effects of adding 0.255 ug/ml amphotericin to Optisol solution (Bausch & Lomb Inc, Bridgewater, NJ).…”