Cost-Effectiveness of Early Irbesartan Treatment Versus Control (Standard Antihypertensive Medications Excluding ACE Inhibitors, Other Angiotensin-2 Receptor Antagonists, and Dihydropyridine Calcium Channel Blockers) or Late Irbesartan Treatment in Patients With Type 2 Diabetes, Hypertension, and Renal Disease

Abstract

OBJECTIVE -The aim of this study was to determine the most cost-effective time point for initiation of irbesartan treatment in hypertensive patients with type 2 diabetes and renal disease. RESEARCH DESIGN AND METHODS-This study was a Markov model-simulated progression from microalbuminuria to overt nephropathy, doubling of serum creatinine, endstage renal disease, and death in hypertensive patients with type 2 diabetes. Two irbesartan strategies were created: early irbesartan 300 mg daily (initiated with microalbuminuria) and late irbesartan (initiated with overt nephropathy). These strategies were compared with control, which consisted of antihypertensive therapy with standard medications (excluding ACE inhibitors, other angiotensin-2 receptor antagonists, and dihydropyridine calcium channel blockers) with comparable blood pressure control, initiated at microalbuminuria. Transition probabilities were taken from the Irbesartan in Reduction of Microalbuminuria-2 study, Irbesartan in Diabetic Nephropathy Trial, and other published sources. Costs and life expectancy, discounted at 3% yearly, were projected over 25 years for 1,000 simulated patients using a third-party payer perspective in a U.S. setting.RESULTS -Compared with control, early and late irbesartan treatment in 1,000 patients were projected to save (mean Ϯ SD) $11.9 Ϯ 3.3 million and $3.3 Ϯ 2.7 million, respectively. Early use of irbesartan added 1,550 Ϯ 270 undiscounted life-years (discounted 960 Ϯ 180), whereas late irbesartan added 71 Ϯ 40 life-years (discounted 48 Ϯ 27) in 1,000 patients. Early irbesartan treatment was superior under a wide-range of plausible assumptions.CONCLUSIONS -Early irbesartan treatment was projected to improve life expectancy and reduce costs in hypertensive patients with type 2 diabetes and microalbuminuria. Later use of irbesartan in overt nephropathy is also superior to standard care, but irbesartan should be started earlier and continued long term.

Drug-Induced Reduction in Albuminuria Is Associated with Subsequent Renoprotection

“…Clinical practice guidelines advocate early detection and appropriate treatment based on the rationale that intervention in the early course of disease may be more advantageous. 1,2 To establish drug efficacy in clinical trials of progression of CKD doubling of serum creatinine and ESRD are used as clinical end points. However, progression of kidney disease to ESRD takes many years to manifest.…”

Pharmacoeconomic Challenges in the Management of Diabetic Nephropathy

“…12 Three treatment strategies were compared: early use of irbesartan (with therapy initiated when microalbuminuria was detected), late use of irbesartan (treatment started when nephropathy developed), and standard antihypertensive therapy with comparable BP control. 12 Data were taken from IRMA II and the IDNT; 12 costs for ESRD and outcomes were obtained from the USRDS. 12 Costs and This study demonstrated that, when compared with standard antihypertensive therapy, early use of irbesartan per 1,000 patients was projected to save $11.9 ± 3 million, and late use of irbesartan was projected to save $3.3 ± $2.7 million.…”

“…12 Data were taken from IRMA II and the IDNT; 12 costs for ESRD and outcomes were obtained from the USRDS. 12 Costs and This study demonstrated that, when compared with standard antihypertensive therapy, early use of irbesartan per 1,000 patients was projected to save $11.9 ± 3 million, and late use of irbesartan was projected to save $3.3 ± $2.7 million. The study also estimated that the early use of irbesartan would add 1,550 ± 270 cumulative life years per 1,000 patients, while late use added only 71 ± 40 cumulative life years.…”

“…This model was also designed to determine the most cost-effective time to start irbesartan-at the microalbuminuric stage as was studied in IRMA II or at the overt stage as was studied in the IDNT. 12 Composite end points of the clinical trial included DSC, ESRD, and death. 12 Three treatment strategies were compared: early use of irbesartan (with therapy initiated when microalbuminuria was detected), late use of irbesartan (treatment started when nephropathy developed), and standard antihypertensive therapy with comparable BP control.…”

“…12 Composite end points of the clinical trial included DSC, ESRD, and death. 12 Three treatment strategies were compared: early use of irbesartan (with therapy initiated when microalbuminuria was detected), late use of irbesartan (treatment started when nephropathy developed), and standard antihypertensive therapy with comparable BP control. 12 Data were taken from IRMA II and the IDNT; 12 costs for ESRD and outcomes were obtained from the USRDS.…”