PHARMACOECONOMICS

Abciximab in coronary stenting: improved smvival 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 l\1Is 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 or large MI, death or any MI, and death, MI or any target-vessel revascularisation.

Also, stenting plus abciximab 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 [71162 (4.3%)] than after stenting plus placebo [191173 (11.1 %)], as was the composite rate of death or large MI [81162 (4.9%) vs 24/173 (14%), respectively]. These results are 'particularly encouraging' , comment the investigators.

Around $US5000-6000 per LYS The cost for the baseline hospital stay was

> SUS 1 000 higher in the stenting plus abciximab group than in the other two groups, largely due to the cost of abciximab and the stents [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 < SUS 1 000 higher in the stenting plus abciximab group.

Cost-effectiveness analysis showed that stenting plus abciximab 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). *

Compared with balloon angioplasty plus abciximab, stenting plus abciximab produced an incremental life expectancy of 0.11 years at an incremental cost of $US581, giving a cost-effectiveness ratio of $US5291ILYS. 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 - health care 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 EP ISTENT­eligible 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 EPISIFNr(EvaIuation of Platelet IlbIIila Inhibitor for StenJing) 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.

**Seealso Inpharma 1188: 6-7, 22 May 1999; 800632787

t In these strategies, abciximab was given at a dosage of 0.25 mglkg up to «J minutes before the inJervention,followed by an iTgUsion of 0.125 J.1g1kg over 1 minute (maximum 10 J.1g1minute)for 12 hours. All patients received oral aspirin 325mg at least 2 hours before the pTrJCel:!ure and daily theTr!Ojter; and ticlopidine 250mg twice daily was started at the discretion of the investigator before the start of the study agent. In the 2 treatmenI groups that received abciximab, patients were also given heparin 70 U/kg as a bolus to achieve a taTget activated clotting time ~ 200 seconds. Plocebo recipienJs were given an initial bolus ofheparin 100 UIkg. and addiJional boluses were given to achieve a taTget activated clotting time of 300 seconds.

t Costs were expressed in 1997 values and were discounJed at 3% per annum. Although the investigators state that they used a societal perspective, prrxluctivity com, nonmedical costs and outpatient costs

(aside from invasive cardiac procedures) were not included. the cost of abciximab was calculatedfora price of$US45<YviaJ, and the cost

of a Palmaz-Schatz stenI was $US1600 (undiscounted).

Topol EJ. Mark DB. Uncoff AM, Coben E, EPISTENT Investigaton. Outcomes at 1 year and economic implications of platelet glycoprotein IThIIIIa blockade in patients undergoing c:oronmy ltenting: results from • multiccntre randomised trial. Lancet 354: 20 19-2024. 11 Dec 1999 IOOIOUIl

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