Cost-effectiveness of prophylaxis against Pneumocystis carinii pneumonia in patients with Wegener's granulomatosis undergoing immunosuppressive therapy

Abstract

Objective. To assess the incremental costeffectiveness of 3 Pneumocystis carinii pneumonia (PCP) prophylaxis strategies in patients with Wegener's granulomatosis (WG) receiving immunosuppressive therapies: 1) no prophylaxis; 2) trimethoprim/sulfamethoxazole (TMP/SMX) 160 mg/800 mg 3 times a week, which is discontinued if patients experience an adverse drug reaction (ADR); and 3) TMP/SMX 160 mg/800 mg 3 times a week, which is replaced by monthly aerosolized pentamidine (300 mg) if patients experience an ADR.Methods. A Markov state-transition model was developed to follow a hypothetical cohort of WG patients over their lifetimes starting from the time of initial exposure to the immunosuppressive therapy. The effect of PCP prophylaxis on life expectancy, quality-adjusted life expectancy, average discounted lifetime cost (ADLC), and incremental cost-effectiveness was estimated based on data obtained from a literature review. Direct medical costs were examined from a societal perspective, and costs and benefits were discounted at 3% annually.Results. No prophylaxis resulted in a life expectancy of 13.36 quality-adjusted life years (QALY) at an ADLC of $4,538. In comparison, prophylaxis with TMP/ SMX alone increased the QALY to 13.54 and was cost saving, with an ADLC of $3,304. The addition of pentamidine in patients who had an ADR to TMP/SMX resulted in 13.61 QALY, with an ADLC of $7,428. Compared with TMP/SMX alone, TMP/SMX followed by pentamidine increased the QALY by 0.07 at an incremental cost of $58,037 per QALY. Both TMP/SMX alone and TMP/SMX followed by pentamidine prophylaxis strategies dominated the no prophylaxis strategy until the incidence of PCP fell below 0.2% and 2.25%, respectively. Institution of pentamidine therapy for patients with a TMP/SMX ADR increased qualityadjusted life expectancy compared with that with TMP/ SMX alone until the incidence of PCP rose above 7.5%.Conclusion. Prophylaxis using TMP/SMX alone increased life expectancy and reduced cost for patients with WG receiving immunosuppressive therapy. Replacing TMP/SMX with monthly aerosolized pentamidine in cases of ADR further increased life expectancy, although at an increased cost.

Is Newer Safer? Adverse Events Associated with First-Line Therapies for ANCA-Associated Vasculitis and Lupus Nephritis

“…Chemoprophylaxis was prescribed (5) or recommended (7) in both AAV trials above but was not noted in the lupus nephritis trials. The use of PCP chemoprophylaxis during CYC treatment is recommended by many experts (23,24) and should be considered with rituximab treatment as well. There are conflicting data about whether MMF may protect against or increase the risk of PCP in renal transplant recipients (25).…”

Erratum: Eular/ERA-EDTA recommendations for the management of ANCA-associated vasculitis

“…We encourage prophylaxis against infection with Pneumocystis jirovecii with trimethoprim/sulfamethoxazole (800/ 160 mg on alternate days or 400/80 mg daily) in all patients being treated with cyclophosphamide, where not contraindicated. [53][54][55] The use of inhaled monthly pentamidine in the event of an adverse reaction or contraindication to trimethoprim/sulfamethoxazole may be useful but is not cost-effective and not routinely indicated. 53 Other alternatives include dapsone and atovaquone.…”

Pneumocystic Pneumonia in Rheumatic Diseases: Current Issues in Prophylaxis

“…Фармакоэконо мический анализ профилактики ко-тримо-ксазолом у больных ГПА продемонстрировал увеличение числа лет, скорректированных по качеству жизни (QALY), и экономию расходов более чем на 1 000 долл. [41].…”