INTERNATIONAL RESEARCH & OPINION

Abciximab during coronaty stenting: improved swvival at acceptable cost

Adjunctive abciximab given at the time of coronary stenting in patients with coronary artery disorders improves survival and is cost effective, report EPISTENT investigators. *

They used data from the EPISTENT trial * * to compare the outcomes and costs associated with the following strategies in patients undergoing percuta­neous coronary revascularisation: • stenting plus abciximab • stenting plus placebo • balloon angioplasty plus abciximab,t

Significantly fewer deaths and MIs Based on intent-to-treat analysis at I-year follow-up,

there was a 57% reduction in mortality and a 53% reduction in the rate of large myocardial infarction (MI) in the group that received stenting plus abciximab, compared with the group that received stenting plus placebo [see table]. Furthermore, the rate of sudden death was significantly lower in the stenting plus abciximab group than in the stenting plus placebo group (0.1 vs 0.9%, respectively), as were the rates of any MI, death/large MI, death/any MI, deathlMliany target-vessel revascularisation.

Also, stenting plus abcixirnab resulted in significantly better outcomes among the subset of patients with diabetes mellitus. In this subset, the large-MI rate was significantly lower after stenting plus abciximab [7/162 (4.3%)] than after stenting plus placebo [191173 (11.1%)], as was the composite rate of death/large MI [8/162 (4.9%) vs 241173 (14%), respectively]. These results are 'particularly encouraging', comment the investigators.

Around $US5OOO-$US6000 per LYS The cost of the baseline hospital stay was > $US 1 ()()()

higher in the stenting plus abciximab group than in the other two groups, largely due to the cost for abciximab and stents used [see table]. However, at 1 year, the total cost of care (including the baseline hospitalisation as well as hospital and professional services during follow-up) was < $US 1000 higher in the stenting plus abciximab group.

Cost-effectiveness analysis showed that stenting plus abcixirnab provided an incremental life expectancy

of 11 years per survivor or 0.15 years per patient treated, at an incremental cost of $US932, compared with stenting plus placebo, giving a cost-effectiveness ratio of $US6213 per life-year saved (LYS). t

Compared with balloon angioplasty plus abciximab, stenting plus abciximab produced an incremental life expectancy of 0.11 years at an incremental cost of $US5~ 1, gIvmg a cost-effectiveness ratio of $US529li LYS. These ratios compare favourably with other widely used therapies, comment the investigators.

The investigators estimated that for every 1000 patients undergoing percutaneous coronary revasculari­sation receiving stenting plus abciximab - instead of stent alone or balloon angioplasty plus abciximab -hea1thcare costs would increase by about $US600 000 to $US900 000. However, this increase would allow 14 extra patients to survive on average for> 10 years, they note. Although the survival benefit is particularly pronounced among patients with diabetes, the investi­gators comment that 'withholding of this new strategy from any EPISTENT-eligible patient on the basis of subgroup analyses of this trial would be inappropriate'.

'With lower device and drug costs, the combination of stenting and abciximab could be an economically dominant strategy by lowering the cost of acute care and extending life expectancy' , conclude the investi­gators. * The EPlSTENT (Evaluation of Platelet lIh/IlIa Inhibitor for Stenting) trial was a large-scale, randomised study conducted in 63 hospitals in Canada and the US. Two of the investigators were affiliated with Centocor; Inc., US. ** see also PharmacoEconomics & Outcomes News 212: 8-9, 15 May 1999; 800632787 t In these strategies, abciximab was given at a dosage of 0.25 mg/kg up to 60 minutes before the intervention, followed by an infusion ofO.125Ilg/kg over 1 minute (maximum 10 Ilg/min)for 12 hours. All patients received oral aspirin 325mg at least 2 hours before the procedure and daily there­after; and ticlopidine 250mg twice daily was staned at the discretion of the investigator before the stan of the study agent. In the two treatment groups that received abciximab, patients were also given heparin 70 U/kg as a bolus to achieve a target activated clotting time of? 200 seconds. Placebo recipients were given an initial bolus of heparin 100 U/kg, and additional boluses were given to achieve a target activated clotting time of 300 seconds. j Costs were expressed in 1997 values and were discounted at 3% per annum. Although the investigators state that they used a societal perspective, productivity costs, nonmedical costs and outpatient costs (aside from invasive cardiac procedures) were not included. The cost of abciximab was calculated for a price

Outcomes, cost and cost effectiveness of different strategies for patients undergoing percutaneous coronary revascularisation

8IIntIna + .tx:bdrn8b StentIng + pIecebo Belloon + .tx:bdrn8b Dea1hII iV794 (1 .OibY lWBUii {2..<i'ibj 17li;G (2.1-')

Large myocardaJ Infarc1Ion 35f794 (4.4%)- 741809 (9.2%) 51/796 (8.4%>"

CoMa (SUS):

Buellne hoapiIaI stay 13228 (n = 480) 11 923 (n = 483) 11 357 (n .. 475)

MecicaI C8/8" during 1-year follow-up 4723 5096 8013

Totalf at 1-year 17951 17019 17370

• P S 0.039 versus III8nting + placebo

.. ho8pItaI and professlonall8lVloes

I t Includes baseline hospital slay costs and follow-up costs

1173.5503199/0243-00071$01.00° Adlaln1ern.tlon.1 Limited 19119. All rlghta reserved PharmacoEconomics & Outcomes News 18 Dec 19119 No. 243

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8 INTERNATIONAL RE SEARCH & OPINION

of $US45{)/J;ial, and the cost of a PaJ~I-SCJw.11 sum ",as $USl600 (undiscoWlled). Topol EJ. Mark DB. Lincoff AM, Cohen E. EPISTENT InvcstigalQn. OIll<:onx:S .. 1 I year and o::onomic implications of pbtdct glycoprou:in IIbIIII.. b10cUde in patients undc:rgoin~ coronary 'tenting: resuhs from il mulli<;enltC randomiscd trial. l...ln«i 354: 2019·2024, II Dec 1999 _ ".,

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