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Ann Intern Med. 2014 Nov 4;161(9):617-26. doi: 10.7326/M14-0227.

Cost-effectiveness of allopurinol and febuxostat for the management of gout.

Abstract

BACKGROUND:

Gout is the most common inflammatory arthritis in the United States.

OBJECTIVE:

To evaluate the cost-effectiveness of urate-lowering treatment strategies for the management of gout.

DESIGN:

Markov model.

DATA SOURCES:

Published literature and expert opinion.

TARGET POPULATION:

Patients for whom allopurinol or febuxostat is a suitable initial urate-lowering treatment.

TIME HORIZON:

Lifetime.

PERSPECTIVE:

Health care payer.

INTERVENTION:

5 urate-lowering treatment strategies were evaluated: no treatment; allopurinol- or febuxostat-only therapy; allopurinol-febuxostat sequential therapy; and febuxostat-allopurinol sequential therapy. Two dosing scenarios were investigated: fixed dose (80 mg of febuxostat daily, 0.80 success rate; 300 mg of allopurinol daily, 0.39 success rate) and dose escalation (≤120 mg of febuxostat daily, 0.82 success rate; ≤800 mg of allopurinol daily, 0.78 success rate).

OUTCOME MEASURES:

Discounted costs, discounted quality-adjusted life-years, and incremental cost-effectiveness ratios.

RESULTS OF BASE-CASE ANALYSIS:

In both dosing scenarios, allopurinol-only therapy was cost-saving. Dose-escalation allopurinol-febuxostat sequential therapy was more costly but more effective than dose-escalation allopurinol therapy, with an incremental cost-effectiveness ratio of $39 400 per quality-adjusted life-year.

RESULTS OF SENSITIVITY ANALYSIS:

The relative rankings of treatments did not change. Our results were relatively sensitive to several potential variations of model assumptions; however, the cost-effectiveness ratios of dose escalation with allopurinol-febuxostat sequential therapy remained lower than the willingness-to-pay threshold of $109 000 per quality-adjusted life-year.

LIMITATION:

Long-term outcome data for patients with gout, including medication adherence, are limited.

CONCLUSION:

Allopurinol single therapy is cost-saving compared with no treatment. Dose-escalation allopurinol-febuxostat sequential therapy is cost-effective compared with accepted willingness-to-pay thresholds.

PRIMARY FUNDING SOURCE:

Agency for Healthcare Research and Quality.

PMID:
25364883
DOI:
10.7326/M14-0227
[Indexed for MEDLINE]

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