Download cost-effectiveness of indapamide in patients with mild-to

COST-EFFECTIVENESS OF INDAPAMIDE IN PATIENTS WITH
MILD-TO-MODERATE HYPERTENSION
Panagiotis C. Stafylas,1 MD, MSc, Pantelis Sarafidis,1 MD, PhD,
Anastasios Lasaridis,1 MD, PhD, Vassilis Aletras,2 MBA, PhD
1) 1st Department of Medicine, AHEPA University Hospital, Thessaloniki, Greece
2) Department of Business Administration, University of Macedonia, Thessaloniki, Greece
OBJECTIVES
Hypertension is one of the most common cardiovascular
risk factors which affects approximately 1 billion individuals
worldwide. The prevalence of hypertension in Greece is
about 30%. Treatment of hypertension has been shown to
reduce morbidity and mortality and to be one of the most
cost-effective activities carried out in the health field.
Indapamide is one of the most frequently prescribed
diuretics in Greece and the most expensive too. The purpose
of this study was to compare the cost-effectiveness of
indapamide with propranolol, amlodipine, enalapril and
irbesartan in the management of mild-to-moderate
hypertension in Greece.
METHODS
A cost-effectiveness analysis was performed. A decision
analysis model was developed to compare the five alternative
interventions. The analysis began at the point where the
decision to initiate drug therapy with a single agent had been
taken. The model assumed a comprehensive initial
evaluation visit 1 month after drug therapy began. If blood
pressure control was achieved, patients were re-evaluated
every 4 months (periodic clinical and laboratory monitoring).
Patients who did not achieve adequate control were given a
higher dose of the same agent. If control was still not
achieved or the patients experienced intolerable side effects,
they were switched to a single agent from another
therapeutic class. Clinical inputs were derived from
randomized controlled trials and cost data from public
sources. The DerSimonian and Laird method was used for
the meta-analysis.
The evaluation of the cost of managing hypertension
includes the cost of drug therapy, monitoring, treating sideeffects, poor compliance and switching. All costs were
calculated from the perspective of the public insurance
system organizations, in 2004 Euros (€). Future costs and
clinical benefits were discounted at 5%. The time horizon
was 5 years. Sensitivity analyses were performed. The
primary outcome measure was the 5-year NNT to prevent
one death.
RESULTS
Old and new drugs provided similar protection against
total mortality and major CVD events in mild-to-moderate
uncomplicated hypertension (Table 1). The 5-year NNT to
prevent one death was 143 and just 34 patients had to receive
one antihypertensive agent for five years to prevent one
major CVD event (Table 2).
Table 1. Random effects meta-analysis comparing new vs old
antihypertensive agents.
Outcome
No. of Trials
RR
95% CI
P* value
Total mortality
CVD events
15
14
0.98
1.00
0.95-1.02
0.95-1.04
.92
.006
Abbreviations: RR ─ relative risk; CI ─ confidence interval; P ─ value
for heterogeneity across combined trials; CVD ─ cardiovascular disease.
* P <.05 indicates heterogeneity of treatment effects across combined trials.
Correspondence: Panagiotis C. Stafylas, MD, MSc,
1st Department of Medicine, AHEPA University Hospital,
St. Kiriakidi 1, 54006, Thessaloniki, Greece.
Tel: +30 2310 588298, Fax: +30 2310 994616
e-mail: [email protected], [email protected]
The five-years total treatment cost was €550.99, €582.04,
€864.32, €622.30 and €1283.99 for indapamide, propranolol,
amlodipine, enalapril and irbesartan respectively and the estimated
total cost to prevent one major cardiovascular event was €16239.77,
€17154.91, €25474.88, €18341.68 and €37844.09 respectively
(Figure 1). Sensitivity analyses confirmed the lower costeffectiveness ratio of indapamide in comparison with propranolol,
amlodipine, enalapril or irbesartan.
Table 2. Random effects meta-analysis comparing any antihypertensive
drug treatment vs no treatment or placebo.
No. of
P* 5-year 95%
P*
RR 95% CI
Trials
value NNT
CI
value
Total mortality 28
0.90 0.85-0.95 .51
143 97 - 833 .43
CVD events
27
0.79 0.74-0.85 .008
34
30 - 66 .015
Outcome
Abbreviations: RR – relative risk; NNT ─ number-needed-to-treat; CI ─
confidence interval; P ─ value for heterogeneity across combined trials; CVD ─
cardiovascular disease.
* P <.05 indicates heterogeneity of treatment effects across combined trials.
160000
140000
120000
100000
72151,51
68303
80000
60000
16240
40000
17155
20000
0
Death
Indapamide
Propranolol
CVD event
Amlodipine
Enalapril
Irbesartan
Abbreviations: CVD ─ cardiovascular disease.
Figure 1. Total 5-year treatment costs (€) to prevent one death or one
cardiovascular event.
CONCLUSIONS
In the management of mild-to-moderate hypertension in Greece,
indapamide is more cost-effective than propranolol, amlodipine,
enalapril or irbesartan. The results of this study support the last
recommendations of the Joint National Committee and the
International Society of Hypertension. Indapamide should be
considered as the first choice of antihypertensive treatment in
uncomplicated hypertension.
REFERENCES
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Organization (WHO)/International Society of Hypertension (ISH) statement on
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2. Chobanian A, et al. The seventh report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC
7 Report. JAMA 2003; 289: 2560 – 2572.
3. Mancia G, et al. 2003 European Society of Hypertension – European Society of
Cardiology guidelines for the management of arterial hypertension. J Hypertension
2003; 21: 1011 – 1053.
4. Sarafidis P, et al. Prevalence, awareness, treatment and control of hypertension
in employees of factories of Northern Greece: the Naoussa study. J Hum Hypertens
2004; 18: 623 – 629.
5. Stafilas PC, et al. An economic evaluation of the 2003 European Society of
Hypertension-European Society of Cardiology guidelines for the management of
mild-to-moderate hypertension in Greece. Am J Hypertens. 2005 Sep;18(9 Pt
1):1233-40.