Abstract
Background
Hyperphosphatemia is a common and potentially harmful condition in patients with end-stage
kidney disease. In Canada, first-line treatment of hyperphosphatemia consists primarily
of calcium carbonate (CC). Lanthanum carbonate (LC) and sevelamer hydrochloride (SH)
are non–calcium phosphate binders that have been used as second-line therapy in patients
intolerant of or not responsive to CC.
Objectives
The primary objective of the present study was to assess the costs and clinical benefits
of second-line use of LC after therapy failure with CC in patients receiving dialysis,
from a Canadian payer perspective. The secondary objective was to perform an economic
comparison between second-line LC therapy and second-line SH therapy, from a Canadian
payer perspective. Short-term outcomes were treatment response and cost per additional
responder, and long-term outcomes were survival, number of all-cause hospitalizations,
and quality of life.
Methods
A cost-effectiveness Markov model was populated with simulated cohorts of 1000 patients
receiving incident dialysis, followed life-long. Patients not responsive to CC with
a serum phosphate concentration >1.78 mmol/L (>5.5 mg/dL) received a trial regimen
with LC. Patients not responsive to LC returned to CC therapy. Patient data from a
randomized controlled trial of 800 patients receiving dialysis were used. Extensive
(probabilistic) sensitivity analyses were performed. When available, model parameters
were based on Canadian data or from a Canadian perspective. All costs are in 2010
Canadian dollars (C$).
Results
Results of the model estimated that in patients responsive to second-line LC therapy,
survival increased, on average, 0.44 years (95% confidence interval [CI], 0.35–0.54)
per patient when compared with continued CC therapy. The mean (range) costs per patient
in the first year of treatment with LC was C$2600 (C$2400–C$2800). Over patients'
lifetimes, the second-line LC strategy resulted in a gain of 48.8 (37.1–61.3) life-years
and 29.3 (21.4–38.1) quality-adjusted life-years (QALYs). The cost-effectiveness of
the second-line LC strategy was C$7900 (C$1800–C$14,600) per life-year and C$13,200
(C$3000–C$25,100) per QALY gained. Most sensitivity analyses did not change the cost-effectiveness
outcomes; however, including unrelated future costs raised the incremental cost-effectiveness
ratio to C$159,500 (95% confidence interval, C$133,300–C$191,600) per QALY gained.
Compared with second-line SH therapy, second-line LC therapy had similar effectiveness
and was 23% less expensive.
Conclusions
Second-line treatment with LC is cost-effective in the treatment of end-stage kidney
disease in patients with hyperphosphatemia, from a Canadian payer perspective. Second-line
treatment with LC is less expensive, with similar effectiveness as second-line treatment
with SH. The primary limitation of health economic evaluations of phosphate binders
is the relative scarcity of clinical data on the association between phosphate concentration
and long-term outcome.
Key words
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Article info
Publication history
Published online: June 29, 2012
Accepted:
June 6,
2012
Identification
Copyright
© 2012 Elsevier HS Journals, Inc. Published by Elsevier Inc. All rights reserved.
