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Cost-effectiveness of duloxetine in chronic low back pain: a Quebec societal perspective.
Spine (Phila Pa 1976). 2013 May 15; 38(11):936-46.S

Abstract

STUDY DESIGN

Cost-effectiveness model from a Quebec societal perspective using meta-analyses of clinical trials.

OBJECTIVE

To evaluate the cost-effectiveness of duloxetine in chronic low back pain (CLBP) compared with other post-first-line oral medications.

SUMMARY OF BACKGROUND DATA

Duloxetine has recently received a CLBP indication in Canada. The cost-effectiveness of duloxetine and other oral medications has not previously been evaluated for CLBP.

METHODS

A Markov model was created on the basis of the economic model documented in the 2008 osteoarthritis clinical guidelines of the National Institute for Health and Clinical Excellence. Treatment-specific utilities were estimated via a meta-analysis of CLBP clinical trials and a transfer-to-utility regression estimated from duloxetine CLBP trial data. Adverse event rates of comparator treatments were taken from the National Institute for Health and Clinical Excellence model or estimated by a meta-analysis of clinical trials in osteoarthritis using a maximum-likelihood simulation technique. Costs were developed primarily from Quebec and Ontario public sources as well as the published literature and expert opinion. The 6 comparators were celecoxib, naproxen, amitriptyline, pregabalin, hydromorphone, and oxycodone. Subgroup analyses and 1-way and probabilistic sensitivity analyses were performed.

RESULTS

In the base case, naproxen, celecoxib, and duloxetine were on the cost-effectiveness frontier, with naproxen the least expensive medication, celecoxib with an incremental cost-effectiveness ratio of $19,881, and duloxetine with an incremental cost-effectiveness ratio of $43,437. Other comparators were dominated. Key drivers included the rates of cardiovascular and gastrointestinal adverse events and proton pump inhibitor usage. In subgroup analysis, the incremental cost-effectiveness ratio for duloxetine fell to $21,567 for a population 65 years or older and to $18,726 for a population at higher risk of cardiovascular and gastrointestinal adverse events.

CONCLUSION

The model estimates that duloxetine is a moderately cost-effective treatment for CLBP, becoming more cost-effective for populations older than 65 years or at greater risk of cardiovascular and gastrointestinal events.

LEVEL OF EVIDENCE

1.

Authors+Show Affiliations

Medical Decision Modeling Inc., Indianapolis, IN 46268, USA. rwielage@mdm-inc.comNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

23250234

Citation

Wielage, Ronald, et al. "Cost-effectiveness of Duloxetine in Chronic Low Back Pain: a Quebec Societal Perspective." Spine, vol. 38, no. 11, 2013, pp. 936-46.
Wielage R, Bansal M, Wilson K, et al. Cost-effectiveness of duloxetine in chronic low back pain: a Quebec societal perspective. Spine (Phila Pa 1976). 2013;38(11):936-46.
Wielage, R., Bansal, M., Wilson, K., Klein, R., & Happich, M. (2013). Cost-effectiveness of duloxetine in chronic low back pain: a Quebec societal perspective. Spine, 38(11), 936-46. https://doi.org/10.1097/BRS.0b013e31828264f9
Wielage R, et al. Cost-effectiveness of Duloxetine in Chronic Low Back Pain: a Quebec Societal Perspective. Spine (Phila Pa 1976). 2013 May 15;38(11):936-46. PubMed PMID: 23250234.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Cost-effectiveness of duloxetine in chronic low back pain: a Quebec societal perspective. AU - Wielage,Ronald, AU - Bansal,Megha, AU - Wilson,Kinsley, AU - Klein,Robert, AU - Happich,Michael, PY - 2012/12/20/entrez PY - 2012/12/20/pubmed PY - 2013/12/16/medline SP - 936 EP - 46 JF - Spine JO - Spine (Phila Pa 1976) VL - 38 IS - 11 N2 - STUDY DESIGN: Cost-effectiveness model from a Quebec societal perspective using meta-analyses of clinical trials. OBJECTIVE: To evaluate the cost-effectiveness of duloxetine in chronic low back pain (CLBP) compared with other post-first-line oral medications. SUMMARY OF BACKGROUND DATA: Duloxetine has recently received a CLBP indication in Canada. The cost-effectiveness of duloxetine and other oral medications has not previously been evaluated for CLBP. METHODS: A Markov model was created on the basis of the economic model documented in the 2008 osteoarthritis clinical guidelines of the National Institute for Health and Clinical Excellence. Treatment-specific utilities were estimated via a meta-analysis of CLBP clinical trials and a transfer-to-utility regression estimated from duloxetine CLBP trial data. Adverse event rates of comparator treatments were taken from the National Institute for Health and Clinical Excellence model or estimated by a meta-analysis of clinical trials in osteoarthritis using a maximum-likelihood simulation technique. Costs were developed primarily from Quebec and Ontario public sources as well as the published literature and expert opinion. The 6 comparators were celecoxib, naproxen, amitriptyline, pregabalin, hydromorphone, and oxycodone. Subgroup analyses and 1-way and probabilistic sensitivity analyses were performed. RESULTS: In the base case, naproxen, celecoxib, and duloxetine were on the cost-effectiveness frontier, with naproxen the least expensive medication, celecoxib with an incremental cost-effectiveness ratio of $19,881, and duloxetine with an incremental cost-effectiveness ratio of $43,437. Other comparators were dominated. Key drivers included the rates of cardiovascular and gastrointestinal adverse events and proton pump inhibitor usage. In subgroup analysis, the incremental cost-effectiveness ratio for duloxetine fell to $21,567 for a population 65 years or older and to $18,726 for a population at higher risk of cardiovascular and gastrointestinal adverse events. CONCLUSION: The model estimates that duloxetine is a moderately cost-effective treatment for CLBP, becoming more cost-effective for populations older than 65 years or at greater risk of cardiovascular and gastrointestinal events. LEVEL OF EVIDENCE: 1. SN - 1528-1159 UR - https://www.unboundmedicine.com/medline/citation/23250234/Cost_effectiveness_of_duloxetine_in_chronic_low_back_pain:_a_Quebec_societal_perspective_ L2 - https://doi.org/10.1097/BRS.0b013e31828264f9 DB - PRIME DP - Unbound Medicine ER -