Economic issues in glycoprotein IIb/IIIa receptor therapy☆,☆☆

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Abstract

Efficacy, safety, and cost will determine the use of glycoprotein IIb/IIIa therapy in patients with acute coronary syndromes or those patients undergoing percutaneous coronary intervention (PCI). Prospective randomized studies with abciximab, eptifibatide, and tirofiban have demonstrated the superior efficacy and relative safety of IIb/IIIa therapy in these 2 broad patient groups. In medical practice, we by necessity make decisions to administer or withhold therapies based on implicit concepts of cost-effectiveness and efficacy and safety. We herein review available economic data on IIb/IIIa therapy to assist in this decision-making process. The procurement costs of the IIb/IIIa receptor antagonists vary considerably for both acute coronary syndrome and patients undergoing PCI. In PCI, these procurement costs range from $436 to $1407 per patient treated with commonly used regimens. Economic substudies of PCI trials with abciximab and tirofiban demonstrate medical cost savings that partially offset drug procurement costs. The number of dollars spent on IIb/IIIa agents per death or myocardial infarction prevented in patients undergoing PCI ranges from $13,000 to $37,000. Abciximab has cost-effectiveness ratios of $4000 to $7000 per life-year saved in patients undergoing PCI. The incremental cost-effectiveness of IIb/IIIa blockade in the setting of planned stenting is unknown. In patients with acute coronary syndrome, procurement costs range from $1050 to $1548 per patient treated. Expenditures per death or myocardial infarction prevented in patients with acute coronary syndrome range from $32,000 to $82,000. Inadequate direct cost data exist to calculate cost effectiveness ratios for this group, but only high-risk patients will likely have cost-effectiveness ratios that most Western health-care systems can afford. (Am Heart J 1999;136:S24-S32)

Section snippets

The procurement cost (price) of glycoprotein IIb/IIIa therapy

The most tangible cost of glycoprotein IIb/IIIA therapy is the price providers pay to the manufacturers. The patient’s indication for therapy generally guides the dose and schedule of administration of the drug, which determines the procurement cost. There are essentially 2 groups of patients in whom these drugs are used and have been studied. The first is the group of patients who are undergoing percutaneous coronary intervention (PCI), and the GP IIb/IIIa blocker is used as an adjunctive

Retrospective studies of incremental cost of glycoprotein IIb/IIIa therapy

There have been a few retrospective reports that provide insight into the impact of glycoprotein IIb/IIIa therapy on the economic outcomes of PCI in routine clinical practice. At this point, these data are limited but highly important to the observation of the performance of these agents in “naturalistic” settings in which length of stay, 1 of the most powerful determinants of health-care cost, is not influenced by study protocol.

An observational study from HCIA’s (Hospital Corporation

Cost-effectiveness of glycoprotein IIb/IIIa therapy

To arrive at the cost-effectiveness of the glycoprotein IIb/IIIa blockers, the procurement costs and, preferably, the incremental cost must be related to their incremental efficacy. The 3 glycoprotein IIb/IIIa blockers have been studied in variable populations so that their comparative efficacy cannot be directly assessed. We have calculated the number of patients who have to be treated with each agent to prevent 1 death or MI over the first 30 days in the population studied in each drug trial.

Summary

The procurement costs of the glycoprotein IIb/IIIa receptor antagonists vary considerably for both patients with ACS and patients undergoing PCI. In PCI, these costs for an 80-kg patient range from $1407 with abciximab, $436 with eptifibatide (with the 180 μg/kg loading dose and 2.0 μg/kg/min infusion dose for 22 hours, a regimen that has not been formally studied), and $780 for tirofiban (with the 10 μg/kg bolus and 0.15 μg/kg/min infusion for 36 hours). In patients with ACS, tirofiban has a

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    ☆

    Reprint requests: William B. Hillegass, MD, MPH, Vanderbilt University Medical Center, 315 MRBII, Nashville, TN 37232-6300.

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    0002-8703/99/$8.00 + 0   4/0/99079

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