摘要:

Third-party payors and national health systems require evidence that new medications for rheumatoid arthritis are cost effective. To determine cost effectiveness, one must consider the cost of a given therapy versus the long-term cost of the disease, with and without therapy. The direct and indirect costs of rheumatoid arthritis over the course of the disease, including the considerable costs related to hospitalization and disability, have been quantified. Resource utilization and treatment costs are high for patients with rheumatoid arthritis, and there is a strong link between functional disability and direct cost of care.Traditional disease-modifying antirheumatic drugs (DMARDs) [such as methotrexate and gold] have limited long-term effects in improving lives and avoiding costs for patients with rheumatoid arthritis. Tumor necrosis factor (TNF) antagonists, the newest class of rheumatoid arthritis drug therapies, significantly improve patient outcomes, including reducing the signs and symptoms of rheumatoid arthritis, improving physical function and health-related quality of life, and inhibiting radiographic damage. Failing to treat rheumatoid arthritis effectively is very costly; effective treatment includes early, aggressive therapy. As a result, the National Health Service in the UK, other societal decision-makers, and third-party payors have recommended the use of TNF antagonists, in many instances, for the treatment of rheumatoid arthritis.The TNF antagonists – infliximab, etanercept, and the most recently approved, adalimumab – address the limitations of traditional DMARDs, thus setting a new therapeutic standard for rheumatoid arthritis. Data from three key studies (Anti-TNF Research Program of the Monoclonal Antibody Adalimumab in Rheumatoid Arthritis, DE019 and DE011) indicate that adalimumab provides a rapid, sustainable, predictable, and significantly greater reduction in the signs and symptoms of rheumatoid arthritis than traditional DMARDs. Adalimumab yields significantly less structural joint damage as measured by the total Sharp scores and scores on its two major components: joint erosions and joint space narrowing. It also improves physical function (as measured by the Health Assessment Questionnaire Disability Index) and health utility (as measured by the Health Utilities Index Mark 3).In conclusion, rheumatoid arthritis and other musculoskeletal diseases are costly, but an upfront investment in highly effective therapies may provide long-term cost savings compared with traditional therapies. The immediate, out-of-pocket costs of TNF antagonists are greater than traditional DMARDs, but with the potential to significantly improve response rates, inhibit structural joint damage, and improve disability and health utility, TNF antagonists have the potential to be more cost effective over the long run. TNF antagonists can be valuable for patients in need and therefore appropriate for reimbursement by national health systems and third-party payors.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

The cancer disease management field took root in the early 1990s. Health plans in the US seeking to aggressively manage cancer reached out to entrepreneurial start-ups that had infused the general principles of managed care into cancer programs. More than two dozen health plans had adopted some form of cancer disease management by the end of the century. However, employers, witnessing the managed care backlash and experiencing difficulty recruiting an adequate pool of skilled labor during flush economic times, have abstained from aggressive management of their workforces’ cancer treatment.Employers, unlike health plans, pay for work loss associated with disability and absenteeism. Hence, the per capita cost of cancer to employers greatly exceeds that of health plans. As the US economy soured in 2000 and healthcare premiums grew at double-digit rates, employers began to abandon their previous reluctance in adopting disease-specific programs. Some employer initiatives to date are not fully-fledged cancer disease management programs; rather, pieces of such programs have been introduced. The return on investment achievable by implementing a comprehensive cancer disease management program, once known to employers and their consultants, will likely spur much greater adoption of such programs in the next 5 years.This review highlights piecemeal efforts where employers have adopted a form of cancer disease management. Attention is given to some of the employer costs associated with cancer, suggesting that greater awareness of the exposure and potential upside will likely result in more employers embracing fully-fledged cancer disease management.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Postmenopausal osteoporosis is characterized by an increased rate of bone turnover accompanied by a reduction in bone mineral density (BMD) that results in an increased risk of fracture, especially of the vertebrae, hip, or wrist. Alendronate (Fosamax®, Fosamax Once-Weekly®), an oral bisphosphonate that inhibits osteoclast-mediated bone resorption and modulates bone metabolism, is a first-line therapy for the management of postmenopausal women with, or at risk of developing, osteoporosis.Alendronate produces sustained increases in BMD and reductions in bone turnover from baseline, and reduces the risk of vertebral, hip, wrist, and other fractures in women with postmenopausal osteoporosis. It also prevents bone loss, and reduces the risk of radiographic or clinical vertebral fracture in postmenopausal osteopenia. Provided administration instructions are followed, alendronate is generally well tolerated. Adverse events are usually transient and are associated with the upper gastrointestinal tract (abdominal pain, nausea, acid regurgitation, dyspepsia); moreover, the incidence of these adverse events with alendronate was similar to those with placebo. More serious events (esophagitis, gastric or duodenal ulceration or bleeding) are uncommon. Once-weekly formulations are as effective and as well tolerated as once-daily alendronate in postmenopausal women.Pharmacoeconomic evaluations suggest that alendronate is a viable treatment option in postmenopausal osteoporosis. The reduction in fracture-related healthcare utilization seen with alendronate results in decreased direct costs, including inpatient or long-term care. Markov state-transition models suggest that this could at least partially offset costs incurred with alendronate therapy. Treatment of women with osteoporosis aged 65 years and older, and postmenopausal women with a previous osteoporotic fracture, are cost-effective strategies. Alendronate is also likely to increase quality-adjusted life-years in any postmenopausal women with osteoporosis.In conclusion, clinical and economic data support the use of alendronate in postmenopausal osteoporosis. It effectively reduces bone turnover, increases BMD, and reduces the risk of osteoporotic fracture in postmenopausal women with established osteoporosis, especially older women with a higher risk of fracture. Although its cost effectiveness in postmenopausal women with osteopenia is not clearly established, alendronate is clinically effective in these patients. In addition, it is generally well tolerated when taken as recommended. Consequently, alendronate should be considered a therapy of choice in the prevention and treatment of osteoporosis in postmenopausal women.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Parkinson disease is a movement disorder caused by progressive dopaminergic neuron degeneration in the substantia nigra and characterized by four cardinal symptoms: resting tremor, bradykinesia, rigidity, and postural instability. Levodopa has been considered the first-choice intervention for Parkinson disease for more than three decades. However, up to 50–90% of levodopa-treated patients develop motor complications within 5–10 years of starting treatment. It is important, therefore, to delay the initiation and/or reduce the dosage requirements of levodopa. The non-ergoline dopamine agonist ropinirole (Requip®) is used as monotherapy or in combination with low-dose levodopa in patients with early disease, and as an adjunct to levodopa in patients with advanced Parkinson disease.As an adjunct to levodopa therapy in patients with more advanced disease, ropinirole is generally more effective than bromocriptine and more effective than placebo. Ropinirole (with or without levodopa) is more effective than placebo and at least as effective as bromocriptine when administered as therapy for early Parkinson disease. It reduces the risk of dyskinesia relative to levodopa and maintains long-term control of the underlying disease symptoms, factors that are associated with improved functional ability. Ropinirole reduced the loss of putamen dopamine storage capacity compared with levodopa in a functional imaging study. However, it was unclear whether this resulted from any neuroprotective activity of ropinirole; further research is required to identify any clinically important neuroprotective activity of dopamine agonists. Ropinirole has a tolerability profile generally similar to that of bromocriptine and levodopa when used as monotherapy. In common with all dopaminergic agents, ropinirole has been linked with sedation and unintended sleep episodes; however, these effects may also result from the underlying disease process in patients with Parkinson disease.Only limited data are available from pharmacoeconomic evaluations of ropinirole. Nevertheless, a cost-minimization analysis indicates that, from a societal viewpoint in Canada, ropinirole is cost saving relative to treatment with levodopa plus a dopa decarboxylase inhibitor in patients with early Parkinson disease. Further economic and quality-of-life assessments of ropinirole are required, particularly comparisons with other dopamine agonists and antiparkinsonian interventions.In conclusion, ropinirole is established as an adjunct to levodopa in advanced Parkinson disease, and as monotherapy or in combination with low-dose levodopa in early disease. It is in the setting of early Parkinson disease that ropinirole may see greatest expansion of its overall role in disease management programs.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Alzheimer disease is a common, progressive neurodegenerative disorder of the elderly, affecting approximately 3% of individuals 65–74 years of age, and up to half of those aged ≥85 years. Along with progressive loss of memory and cognitive function, other symptoms include depression and behavioral and motor disturbances. Some estimates of the cost of Alzheimer disease in the US exceed $US100 billion annually.While no drug clearly slows progression of Alzheimer disease, cholinesterase inhibitors have provided the greatest symptomatic benefit, particularly in improving or delaying the decline in cognitive function. As such, rivastigmine, donepezil, and galantamine are recommended as first-line treatment options for patients with mild to moderate Alzheimer disease.Rivastigmine has been evaluated in a number of clinical trials, including two large multicenter studies in patients with mild to moderate Alzheimer disease. In the observed-case analyses of these 26-week pivotal trials, rivastigmine 3–6mg twice daily was consistently associated with statistically significant benefits versus placebo in key measures of cognition, global function, and activities of daily living. Intent-to-treat analyses showed similar results, with most differences versus placebo achieving statistical significance. Follow-up data of up to 5 years' total duration demonstrated long-term cognitive benefits with continued rivastigmine therapy.As with all cholinesterase inhibitors, gastrointestinal adverse effects including nausea, vomiting, diarrhea, and anorexia are relatively common with rivastigmine. Individualized dosage titration and administration with food are recommended to minimize these problems, which are generally of mild to moderate severity and limited duration.Pharmacoeconomic analyses of rivastigmine in mild to moderate Alzheimer disease indicate that the cost of the drug is essentially off-set by reductions in other costs after about 2 years of therapy, primarily by delaying institutionalization. Most were modeled analyses from the US, Canada, and the UK conducted from societal or provider perspectives.In conclusion, rivastigmine is one of a very limited number of first-line medications for the symptomatic treatment of mild to moderate dementia in Alzheimer disease. Along with improving or delaying the decline in cognitive function, rivastigmine also has beneficial effects on global function, activities of daily living, and behavioral problems. Rivastigmine is also a useful treatment option for patients not responding to therapy with other cholinesterase inhibitors. Potential advantages of rivastigmine include its low drug interaction potential and dual inhibitory effect on both acetyl- and butyrylcholinesterase. Large, randomized comparisons between rivastigmine, donepezil, and galantamine are needed to provide further insight into clinically significant differences between these cholinesterase inhibitors.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS