COST EFFECTIVENESS OF USING TERLIPRESSIN TO TREAT HEPATORENAL SYNDROME

Hepatorenal syndrome (HRS) is the most severe form of acute kidney injury in patients with advanced cirrhosis, and it is associated with high mortality. It is usually diagnosed according to criteria defined by the International Ascites Club. Currently, the most frequently indicated pharmacological therapy for the treatment of HRS is a combination of splanchnic vasoconstrictors (terlipressin or norepinephrine) in combination with albumin. With the progressive increase in healthcare spending, it is important to conduct a cost-effectiveness analysis of pharmacological treatment in patients who are diagnosed with HRS.

Objective:

To perform a cost-effectiveness assessment for the use of terlipressin in combination with albumin to treat HRS in patients with cirrhosis.

Methods:

Economic evaluation of cost-effectiveness based on secondary data from studies showed the efficacy of terlipressin therapy compared with norepinephrine combined with albumin or albumin alone. The cost-effectiveness analysis was calculated using an incremental cost-effectiveness ratio (ICER), and a sensitivity analysis was developed by varying the values of therapies and probabilities. The Brazilian real was the currency used in the analysis, and the results were converted to US dollars.

Results:

After selection, eligibility, and evaluation of the quality of publications, the results demonstrated that administration of terlipressin or norepinephrine in combination with albumin in patients diagnosed with HRS type 1 was efficacious. The cost of treatment with terlipressin in combination with albumin was USD $1,644.06, administration of albumin alone was USD $912.02, and norepinephrine plus albumin was USD $2,310.78. Considering that the combination therapies demonstrated effectiveness, the incremental cost of terlipressin and norepinephrine in combination with albumin was USD $666.73, and an effectiveness of 0.570 was found for terlipressin in combination with albumin and 0.200 for norepinephrine in combination with albumin. The incremental effectiveness was 0.370, and the ICER was USD $1,801.97. Thus, the parameters of increasing cost per therapy and ICER indicated that the combined therapy of terlipressin plus albumin was cost effective compared to albumin alone or norepinephrine plus albumin in a public single-payer healthcare system.

Conclusion:

A cost-effectiveness analysis showed that terlipressin in combination with albumin when administered concomitantly to patients who were diagnosed with type 1 HRS is cost-effective compared to norepinephrine in combination with albumin administered in a controlled environment.

Keywords:
Hepatorenal syndrome; cost-effectiveness evaluation; terlipressin; health care costs; norepinephrine; gastroenterology

Terlipressin + Albumin	14 days	12 months
Medicine	$1,644.06	$1,644.06
HRS transplant	$15,509.14	$46.18
HRS dialysis	$822.00	$5,112.39
HRS attendance	-	$184.73
Death	$630.48	-

Albumin	14 days	12 months
Medicine	$912.02	$912.02
HRS transplant	$15,509.14	$46.18
HRS dialysis	$822.00	$5,112.39
HRS attendance	-	$184.73
Death	$630.48

Norepinephrine + albumin	14 days	12 months
Medicine	$2,310.78	$2,310.78
HRS transplant	$14,895.67	$46,18
HRS dialysis	$822,00	$5,112.39
HRS attendance	-	$184,73
Death	$630,48	-

	Terlipressin + albumin		Albumin		Norepinephrine + albumin		Reference
	Probability (%)	Time (days)	Probability (%)	Time (days)	Probability (%)	Time (days)
	31	90	32	90			(23)
Transplant	30	180	30	180			(22)
‘	67	30			50	30	(25)
Dialysis	42	15	0	15			(21)
	34	4			48	4	(20)
Attendance	27	90	19	90			(18)
	42	15	0	15			(21)
	43	180	37	180			(22)
	57	90	55	90			(23)
	42	180	16	180			(19)
	48	14			20	14	(20)
	83	30			25	30	(25)
	45	14			48	14	(24)
Death	43	90	45	90			(23)
	57	180	63	180			(22)
	51	14			80	14	(20)
	34	48			25	40	(25)
	55	14			52	14	(24)

	Terlipressin + albumin	Norepinephrine + albumin
Cost	$1,644.06	$2,310.78
Incremental Cost	$666.73	_
Effectiveness	0.570	0.200
Incremental effectiveness	0.370	_
ICER	$1,801.97	_

Terlipressin + albumin		Norepinephrine + albumin
Probability	Cost	Probability	Cost	ICER
0.570	$1,644.06	0.200	$2,310.78	$1,801.96
0.570	$1,644.06	0.250	$2,310.78	$2,083.52
0.430	$1,539.68	0.480	$2,310.78	$15,422.30
0.480	$1,539.68	0.430	$2,310.78	$15,422.30
0.570	$1,539.68	0.250	$2,310.78	$2,409.73
0.830	$1,644.06	0.480	$2,310.78	$1,904.93
0.430	$1,644.06	0.480	$2,310.78	$13,334.55
0.450	$1,644.06	0.200	$2,310.78	$2,666.91

Instituto Brasileiro de Estudos e Pesquisas de Gastroenterologia e Outras Especialidades - IBEPEGE. Rua Dr. Seng, 320, 01331-020 São Paulo - SP Brasil, Tel./Fax: +55 11 3147-6227 - São Paulo - SP - Brazil
E-mail: secretariaarqgastr@hospitaligesp.com.br

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[1] Corresponding author: Luciana Bertocco de Paiva Haddad. E-mail: luciana.haddad@hc.fm.usp.br