RESUMO
INTRODUCTION: Vildagliptin is an inhibitor of the enzyme dipeptidyl peptidase 4, indicated for the treatment of type 2 diabetes mellitus, combined or not with metformin. This study aims to evaluate the cost-effectiveness of vildagliptin in the Brazilian context. Areas covered: Using MEDLINE, Cochrane Library, Lilacs and CRD, six studies were selected for the economic models. This study utilised cost data in the Brazilian health system to provide the context. Expert commentary: Type 2 diabetes mellitus is an epidemic disease and represents a challenge for all health care systems. Although guidelines clearly define first-line treatment, there are several other promising treatments. Vildagliptin is one of them, resulting in a mean lifetime increase of 0.31 years compared to metformin alone and 1.19 more life years compared to other metformin combinations. Considering observational data, life years with dual vildagliptin-containing treatments were 0.37 more compared to other dual treatments. However, its high cost versus generic metformin and its unclear safety profile weakens its subsequent cost-effectiveness. Consequently, the incorporation of vildagliptin or its combination with metformin is currently not recommended for the Brazilian Health Care System. This may change as more data becomes available.
Assuntos
Adamantano/análogos & derivados , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Nitrilas/uso terapêutico , Pirrolidinas/uso terapêutico , Adamantano/economia , Adamantano/farmacologia , Adamantano/uso terapêutico , Brasil , Análise Custo-Benefício , Diabetes Mellitus Tipo 2/economia , Inibidores da Dipeptidil Peptidase IV/economia , Inibidores da Dipeptidil Peptidase IV/farmacologia , Inibidores da Dipeptidil Peptidase IV/uso terapêutico , Quimioterapia Combinada , Humanos , Hipoglicemiantes/economia , Hipoglicemiantes/farmacologia , Metformina/administração & dosagem , Metformina/economia , Metformina/uso terapêutico , Modelos Econômicos , Nitrilas/economia , Nitrilas/farmacologia , Pirrolidinas/economia , Pirrolidinas/farmacologia , VildagliptinaRESUMO
BACKGROUND: Amblyomma variegatum is an important cause of morbidity, mortality and economic losses in Africa and the West Indies. Attempts to control and/or eradicate the tick from the Caribbean have largely been unsuccessful because of difficulties relating to the biology of the three-host tick and problems with applying acaricides on a regular basis to free-ranging domestic ruminants. While plastic collars impregnated with insecticides are widely and effectively used in companion animals to control external parasites there is little information on this technology in ruminants. METHODS: Over 21 months we tested the efficacy of slow-release plastic tags impregnated with deltamethrin (7%) and aggregation-attachment pheromones (DPITs) in controlling A. variegatum on free-ranging cattle on two farms on St. Kitts. The tags were replaced every three months or when found to be lost. RESULTS: On sentinel animals fitted with tags containing only aggregation-attachment pheromones there were an average of 23.1 ticks per semi-monthly visit although this number varied considerably, peaking in the dry season around May and being lowest in August to October during the wet season. Significantly fewer ticks (3.5 on average) were found on cattle with DPITs at each visit (P < 0.001). Although the DIPTs provided good control (92% on average), they did not significantly reduce A. variegatum in the environment with tick numbers on sentinels being higher in the second year of the study, despite up to 44% of animals being fitted with DPITs. The tags were economical, costing 0.2% of the 1% flumethrin pour-on treatment widely recommended for A. variegatum control in the Caribbean. The major problem encountered was that 38% of tail tags were lost before they were due for replacement every three months. CONCLUSIONS: Our study has shown that DPITs are cheap to produce, easy to place, only require handling of animals every three months, and are very effective in protecting cattle from A. variegatum. Before DPITs can be considered for eradication programs the problems needing to be addressed include loss of tail tags, particularly in thick vegetation, and the optimum number of animals that must be treated to reduce numbers of ticks in the environment.
Assuntos
Doenças dos Bovinos/parasitologia , Inseticidas/farmacologia , Ixodidae/efeitos dos fármacos , Nitrilas/farmacologia , Feromônios/farmacologia , Piretrinas/farmacologia , Controle de Ácaros e Carrapatos/instrumentação , Animais , Bovinos , Doenças dos Bovinos/epidemiologia , Doenças dos Bovinos/prevenção & controle , Inseticidas/economia , Nitrilas/economia , Feromônios/economia , Piretrinas/economia , Estações do Ano , Vigilância de Evento Sentinela , Controle de Ácaros e Carrapatos/economia , Controle de Ácaros e Carrapatos/métodos , Infestações por Carrapato/economia , Infestações por Carrapato/epidemiologia , Infestações por Carrapato/prevenção & controle , Infestações por Carrapato/veterinária , Índias Ocidentais/epidemiologiaRESUMO
INTRODUCTION: In high-income countries, tamoxifen has been replaced by aromatase inhibitors such as anastrozole in adjuvant hormone therapy for early breast cancer. These drugs target patients with positive hormone receptors, due to the better results achieved for disease-free survival. The cost-effectiveness of this treatment change has not been evaluated in middle income countries. OBJECTIVE: The cost effectiveness of anastrozole vs tamoxifen was assessed during five-years of adjuvant treatment of hormone receptor-positive, post-menopausal early breast cancer patients. MATERIALS AND METHODS: This is a literature-based analysis. The natural history of the breast cancer and the effects of treatment were modeled as a Markov process. Effectiveness was defined as disease-free survival. Transition probabilities for the disease and adverse effects were obtained from the literature. Costs were defined as the median of actual costs provided by health insurance companies and the Colombian National Cancer Institute expressed in 2007 Colombian pesos. Probabilistic sensitivity analysis was performed, along with one way sensitivity analysis was for the costs. RESULTS: Compared with tamoxifen, anastrazol results in an additional relapse-free period of 0.5 years. Each relapse-free year obtained by tamoxifen cost 27,210,604 pesos, or with anastrazol 37,071,337 pesos with a discount rate of 3%. The cost for a sustained-effects scenario were 23,617,400 pesos for tamoxifen and $16,140.282 for anastrazol. CONCLUSIONS: The use of anastrazol has an additional cost per relapse-free year of 7,521,363 pesos (2007). Therefore, for postmenopausal, early breast cancer hormone receptor positive women in Colombia, the cost-effective alternative is tamoxifen used as adjuvant therapy for five years.
Assuntos
Antineoplásicos Hormonais/economia , Antineoplásicos Hormonais/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/economia , Nitrilas/economia , Nitrilas/uso terapêutico , Tamoxifeno/economia , Tamoxifeno/uso terapêutico , Triazóis/economia , Triazóis/uso terapêutico , Anastrozol , Quimioterapia Adjuvante/economia , Análise Custo-Benefício , Intervalo Livre de Doença , Feminino , Humanos , Pós-MenopausaRESUMO
OBJECTIVES: Carry out an economic analysis of the incorporation of anastrozole as adjuvant hormone therapy in postmenopausal women with breast cancer in a Brazilian setting. METHODS: The cost-effectiveness estimate comparing anastrozole to tamoxifen was made from the perspectives of the patient, private health insurance, and government. A Markov model was designed based on data from ATAC trial after 100 months follow-up in a hypothetical cohort of 1000 postmenopausal women in Brazil, using outcomes projections for a 25-year period. Resource utilization and associated costs were obtained from preselected sources and specialists' opinions. Treatment costs varied according to the perspective used. The incremental benefit was inserted in the model to obtain the cost of quality-adjusted life-year gained (QALY). RESULTS: Benefit extrapolations for a 25-year time line showed an estimate of 0.29 QALY gained with anastrozole compared to tamoxifen. The cost-effectiveness ratio per QALY gained depended on which perspective was used. There was an increment of R$ 32.403,00/QALY in the public health system/government, R$ 32.230,00/QALY for private health system, and R$ 55.270,00/QALY for patients. CONCLUSION: The benefit from adjuvant anastrozole in postmenopausal patients with breast cancer is associated to major differences in cost-effectiveness ratio and varies with the different perspectives. According to current WHO parameters, the increment is considered acceptable under public and private health system perspectives, but not from that of the patient.
Assuntos
Antineoplásicos Hormonais/economia , Neoplasias da Mama/tratamento farmacológico , Programas Nacionais de Saúde/economia , Nitrilas/economia , Pós-Menopausa , Triazóis/economia , Idoso , Idoso de 80 Anos ou mais , Anastrozol , Antineoplásicos Hormonais/uso terapêutico , Brasil , Quimioterapia Adjuvante/economia , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Seguro Saúde/economia , Cadeias de Markov , Pessoa de Meia-Idade , Nitrilas/uso terapêutico , Satisfação do Paciente/economia , Pós-Menopausa/efeitos dos fármacos , Anos de Vida Ajustados por Qualidade de Vida , Triazóis/uso terapêuticoRESUMO
OBJECTIVE: Breast cancer, a leading type of cancer in many developing countries, is the most frequent non-cutaneous tumor in Brazil. Hormone therapy is the standard of care in the adjuvant treatment of early-stage, hormone-receptor-positive disease, and both tamoxifen and third-generation aromatase inhibitors are options in postmenopausal women. The comparative cost-effectiveness of different treatment strategies is of considerable interest in societies facing limited resources. METHODS: In an attempt to compare cost-effectiveness of upfront treatment with tamoxifen or anastrozole, the medical and economic results in a hypothetical cohort of 64-year-old postmenopausal women, was analyzed considering the Brazilian healthcare system in 2005, the primary perspective of the private sector, and a lifetime horizon. Data from the ATAC Trial, Markov modeling, a modified Delphi panel, and microcosting (in Brazilian R$) were used to estimate costs and effectiveness of the two upfront strategies. RESULTS: The model estimated a gain of 0.55 discounted life-years for patients receiving anastrozole, relative to those treated with tamoxifen. With an incremental cost of R$ 15,141.15, the model estimated that the cost-effectiveness of anastrozole, in relation to tamoxifen, was R$ 27,326.80. Monte Carlo simulations showed that approximately 50% of the cases fell below the threshold of R$ 29,229.00 per life-year gained, which is recommended by the World Health Organization for Brazil. CONCLUSION: It was concluded that upfront anastrozole is a cost-effective option compared with tamoxifen in the adjuvant treatment of postmenopausal women with hormone-receptor-positive early breast cancer.
Assuntos
Antineoplásicos Hormonais/economia , Neoplasias da Mama/tratamento farmacológico , Nitrilas/economia , Tamoxifeno/economia , Triazóis/economia , Anastrozol , Antineoplásicos Hormonais/uso terapêutico , Brasil , Quimioterapia Adjuvante/economia , Análise Custo-Benefício/economia , Detecção Precoce de Câncer , Feminino , Humanos , Cadeias de Markov , Pessoa de Meia-Idade , Nitrilas/uso terapêutico , Pós-Menopausa , Tamoxifeno/uso terapêutico , Triazóis/uso terapêuticoRESUMO
OBJETIVOS: Análise econômica com dados nacionais sobre a possível incorporação do anastrozol como terapia adjuvante hormonal no câncer de mama em pacientes pós-menopausa. MÉTODOS: Foi feita estimativa de custo-efetividade no tratamento adjuvante do câncer de mama, em mulheres pós-menopausa, do anastrozol versus tamoxifeno em três perspectivas: do paciente, de planos de saúde e do governo. Modelo de Markov foi desenvolvido utilizando dados extraídos de publicação do estudo ATAC após seguimento de 100 meses, com projeção de desfechos em 25 anos para uma coorte hipotética de 1000 pacientes com câncer de mama pós-menopausa no Brasil. Dados de utilização de recursos e custos associados foram obtidos de fontes preestabelecidas e de opinião de especialistas. O custo associado aos tratamentos foi extraído separadamente, dependendo do ponto de vista estudado. O benefício foi inserido no modelo para obtenção do custo por ano de vida ganho ajustado pela qualidade (QALY). RESULTADOS: Extrapolando benefícios encontrados para 25 anos de seguimento, o anastrozol, em relação ao tamoxifeno, resultou numa estimativa de ganho de 0,29 QALY. A razão de custo-efetividade por QALY ganho dependeu da perspectiva utilizada. Houve incremento de R$ 32.403,00/QALY no ponto de vista do SUS; de R$ 32.230,00/QALY no dos planos de saúde; e de R$ 55.270,00/QALY no das pacientes. CONCLUSÃO: O benefício encontrado no uso do anastrozol adjuvante em pacientes com câncer de mama operado na pós-menopausa está associado a grandes diferenças na razão de custo-efetividade, dependendo da perspectiva utilizada para o cálculo. Comparando com parâmetros usualmente aceitos pela OMS, o incremento é aceitável sob a perspectiva do SUS e dos planos de saúde, mas não sob a ótica do paciente.
OBJECTIVES: Carry out an economic analysis of the incorporation of anastrozole as adjuvant hormone therapy in postmenopausal women with breast cancer in a Brazilian setting. METHODS: The cost-effectiveness estimate comparing anastrozole to tamoxifen was made from the perspectives of the patient, private health insurance, and government. A Markov model was designed based on data from ATAC trial after 100 months follow-up in a hypothetical cohort of 1000 postmenopausal women in Brazil, using outcomes projections for a 25-year period. Resource utilization and associated costs were obtained from preselected sources and specialists' opinions. Treatment costs varied according to the perspective used. The incremental benefit was inserted in the model to obtain the cost of quality-adjusted life-year gained (QALY). RESULTS: Benefit extrapolations for a 25-year time line showed an estimate of 0.29 QALY gained with anastrozole compared to tamoxifen. The cost-effectiveness ratio per QALY gained depended on which perspective was used. There was an increment of R$ 32.403,00/QALY in the public health system/government, R$ 32.230,00/QALY for private health system, and R$ 55.270,00/QALY for patients. CONCLUSION: The benefit from adjuvant anastrozole in postmenopausal patients with breast cancer is associated to major differences in cost-effectiveness ratio and varies with the different perspectives. According to current WHO parameters, the increment is considered acceptable under public and private health system perspectives, but not from that of the patient.
Assuntos
Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-Idade , Antineoplásicos Hormonais/economia , Neoplasias da Mama/tratamento farmacológico , Programas Nacionais de Saúde/economia , Nitrilas/economia , Pós-Menopausa , Triazóis/economia , Antineoplásicos Hormonais/uso terapêutico , Brasil , Quimioterapia Adjuvante/economia , Análise Custo-Benefício , Custos de Cuidados de Saúde/estatística & dados numéricos , Seguro Saúde/economia , Cadeias de Markov , Nitrilas/uso terapêutico , Satisfação do Paciente/economia , Pós-Menopausa/efeitos dos fármacos , Anos de Vida Ajustados por Qualidade de Vida , Triazóis/uso terapêuticoRESUMO
OBJECTIVE: Breast cancer, a leading type of cancer in many developing countries, is the most frequent non-cutaneous tumor in Brazil. Hormone therapy is the standard of care in the adjuvant treatment of early-stage, hormone-receptor-positive disease, and both tamoxifen and third-generation aromatase inhibitors are options in postmenopausal women. The comparative cost-effectiveness of different treatment strategies is of considerable interest in societies facing limited resources. METHODS: In an attempt to compare cost-effectiveness of upfront treatment with tamoxifen or anastrozole, the medical and economic results in a hypothetical cohort of 64-year-old postmenopausal women, was analyzed considering the Brazilian healthcare system in 2005, the primary perspective of the private sector, and a lifetime horizon. Data from the ATAC Trial, Markov modeling, a modified Delphi panel, and microcosting (in Brazilian R$) were used to estimate costs and effectiveness of the two upfront strategies. RESULTS: The model estimated a gain of 0.55 discounted life-years for patients receiving anastrozole, relative to those treated with tamoxifen. With an incremental cost of R$ 15,141.15, the model estimated that the cost-effectiveness of anastrozole, in relation to tamoxifen, was R$ 27,326.80. Monte Carlo simulations showed that approximately 50 percent of the cases fell below the threshold of R$ 29,229.00 per life-year gained, which is recommended by the World Health Organization for Brazil. CONCLUSION: It was concluded that upfront anastrozole is a cost-effective option compared with tamoxifen in the adjuvant treatment of postmenopausal women with hormone-receptor-positive early breast cancer.
OBJETIVO: O câncer de mama, o mais comum em vários países desenvolvidos, é o tumor não cutâneo mais frequente no Brasil. A terapia hormonal é o tratamento adjuvante padrão para os estágios precoces, em doença com receptor hormonal positivo, e o tamoxifeno e os inibidores da aromatase de terceira geração são opções para mulheres na pós-menopausa. A comparação do custo-efetividade dos diferentes tratamentos é de grande interesse nas sociedades com limitações de recursos. MÉTODOS: Para comparar a custo-efetividade dos tratamentos com tamoxifeno ou anastrozol, foram analisados os resultados médicos e econômicos em uma coorte hipotética de mulheres com 64 anos de idade, considerando o sistema de saúde Brasileiro em 2005, sob a perspectiva do setor privado e o horizonte de tempo de uma vida. Usamos dados do Estudo ATAC, um modelo de Markov, um painel de Delphi modificado, e micro-costing (em reais R$) para estimar os custos e a efetividade das duas estratégias. RESULTADOS: O modelo estimou um ganho de 0.55 anos de vida descontados para pacientes recebendo anastrozol em relação àquelas tratadas com tamoxifeno. Com um custo marginal de R$ 15.141,15, o modelo estimou que o custoefetividade do anastrozol em relação ao tamoxifeno era de R$ 27.326,80. As simulações de Monte Carlo mostraram que aproximadamente 50 por cento dos casos estavam abaixo do limite de R$ 29.229,00 por ano-vida ganho, que é o recomendado pela Organização Mundial da Saúde para o Brasil. CONCLUSÃO: Nós concluímos que o anastrozol é uma opção custo-efetivo comparado ao tamoxifeno no tratamento adjuvante de câncer de mama precoce em mulheres na pós-menopausa com receptor de hormônio positivo.
Assuntos
Feminino , Humanos , Pessoa de Meia-Idade , Antineoplásicos Hormonais/economia , Neoplasias da Mama/tratamento farmacológico , Nitrilas/economia , Tamoxifeno/economia , Triazóis/economia , Antineoplásicos Hormonais/uso terapêutico , Brasil , Quimioterapia Adjuvante/economia , Análise Custo-Benefício/economia , Detecção Precoce de Câncer , Cadeias de Markov , Nitrilas/uso terapêutico , Pós-Menopausa , Tamoxifeno/uso terapêutico , Triazóis/uso terapêuticoRESUMO
OBJECTIVE: To determine the effect of combined therapy of letrozole (2.5 mg or 5.0 mg) with recombinant follicle-stimulating hormone (FSH) in comparison with the administration of recombinant FSH alone in an intrauterine insemination (IUI) program. DESIGN: Retrospective study. SETTING: Assisted fertilization program in a specialized infertility center. PATIENT(S): 110 women undergoing IUI and gonadotropin therapy. INTERVENTION(S): Recombinant FSH alone administered from day 3 or combined with letrozole, 2.5 or 5.0 mg/day, on days 3 to 7, and gonadotropins starting on day 7 of the menstrual cycle. Transvaginal ultrasound examinations were done until the dominant follicle reached 18 mm in diameter. Ovulation was triggered with 10,000 IU of human chorionic gonadotropin (hCG), and IUI performed 30 to 40 hours later. MAIN OUTCOME MEASURE(S): Recombinant FSH dose required, number of follicles greater than 14 mm and 18 mm, endometrial thickness, pregnancy rates, miscarriages, and characteristics of newborns. RESULT(S): Women treated with FSH and 5.0 mg/day of letrozole required a lower dose of FSH than the group cotreated with 2.5 mg/day of letrozole or with FSH alone. Throughout most of the follicular phase, the endometrial thickness was statistically significantly less in both letrozole cotreatment groups compared with the FSH control group. By the day of hCG administration, the endometrial thickness was comparable among all the groups. The pregnancy rates were the same with recombinant FSH alone or combined with letrozole. CONCLUSION(S): In terms of cost-effectiveness, 5.0 mg/day of letrozole is more effective than the 2.5 mg/day in cotreatment with no adverse effect on pregnancy rate or outcome.
Assuntos
Inibidores da Aromatase/administração & dosagem , Fármacos para a Fertilidade Feminina/administração & dosagem , Hormônio Foliculoestimulante/administração & dosagem , Infertilidade/terapia , Inseminação Artificial , Nitrilas/administração & dosagem , Indução da Ovulação , Ovulação/efeitos dos fármacos , Triazóis/administração & dosagem , Aborto Espontâneo/etiologia , Adulto , Inibidores da Aromatase/efeitos adversos , Inibidores da Aromatase/economia , Gonadotropina Coriônica/administração & dosagem , Análise Custo-Benefício , Esquema de Medicação , Custos de Medicamentos , Quimioterapia Combinada , Endométrio/diagnóstico por imagem , Endométrio/efeitos dos fármacos , Feminino , Fármacos para a Fertilidade Feminina/efeitos adversos , Fármacos para a Fertilidade Feminina/economia , Humanos , Inseminação Artificial/economia , Letrozol , Nascido Vivo , Nitrilas/efeitos adversos , Nitrilas/economia , Indução da Ovulação/economia , Gravidez , Taxa de Gravidez , Gravidez Múltipla , Proteínas Recombinantes/administração & dosagem , Estudos Retrospectivos , Resultado do Tratamento , Triazóis/efeitos adversos , Triazóis/economia , UltrassonografiaRESUMO
OBJECTIVE: To compare the efficiency of adjuvant therapy with aromatase inhibitors or with tamoxifen in postmenopausal women with operable breast cancer and positive estrogen receptors. MATERIAL AND METHODS: A cost-utility analysis was performed based on a Markov model, from the Spanish National Health Care System perspective, comparing the treatment with exemestane (EXE: 25 mg/day) or tamoxifen (TAM: 20 mg/day) after 2-3 years of monotherapy with TAM; anastrozole (ANA, 1 mg/day) or TAM (20 mg/day) without previous TAM therapy; and letrozole (LET: 2.5 mg/day) or placebo after 5 years of monotherapy with TAM. The follow-up of a hypothetical cohort of women starting treatment at 63 years of age was simulated during 10 and 20 years. The probabilities of transition between health states and quality adjusted life years (QALYs) were obtained from the literature, and the unit costs (euro corresponding to 2004) from a Spanish database. RESULTS: After 10 and 20 years of follow-up, more QALYs per patient would be gained with the EXE scheme (0.230-0.286 and 0.566-0.708, respectively) than with ANA (0.114 and 0.285) and LET (0.176 and 0.474). The cost of gaining one QALY was lower with the EXE scheme (50,801-62,522 euro and 28,849- 35,371 euro, respectively) than with ANA (104,272 euro and 62,477 euro) and LET (91,210 euro and 49,460 euro). The result was stable for the cost per life-year gained (LYG) and in the sensitivity analysis. CONCLUSIONS: The EXE scheme after TAM is more cost-effective than the ANA and LET schemes.