Two-hour post-dose cyclosporine levels in renal transplantation in Argentina: a cost-effective strategy for reducing acute rejection.
Monitoring of cyclosporine (microemulsion CsA) at 2 hours post-dose (C2), a measure of absorption and exposure, appears superior to trough (C0) monitoring for prediction of rejection risk. The purpose of this study was to determine whether C2 was cost-effective compared to C0 in Argentina.


METHODS
A predictive decision model was adapted to Argentina to predict costs associated with C0 and C2 measurements in the first year after transplantation. Patients were treated with microemulsion CsA, steroids and azathioprine or MMF. Parameter estimates for the C0 strategy were based on event rates observed in published clinical trials. The model was adapted to Argentinean health system through local protocols and expert opinions; costs were valued in Argentinean pesos and converted to US dollars (1 USD = 2.85 ARS).


RESULTS
Incidence of acute rejection was predicted to be 25.0% at 1-year among patients monitored by C0 and 18.0% by C2. Graft survival was predicted to be 1.4% lower in the C0 group. No important differences were identified in co-morbidity, C0 and C2 monitoring costs, and in ambulatory-based adverse events between C0 and C2 cohorts. The model predicted an average cost per patient of $16,269 for C0 and $16,343 for C2 testing (year 1). Sensitivity analyses indicated that the average daily dose of microemulsion CsA was the most important parameter leading to the incremental cost per patient.


CONCLUSIONS
C2 is expected to provide a potentially important reduction in the risk of acute rejection without increasing the estimated cost of care in the first year post-transplant.
Balshaw
R
R
Fraser University, Burnaby, British Columbia, Canada. rob.balshaw@syreon.com
Machnicki
G
G
Carreño
C Agost
CA
Toselli
L
L
Otero
A
A
Keown
P A
PA
D000208:Acute Disease; D001118:Argentina; D001379:Azathioprine / Q000627:therapeutic use; D003365:Costs and Cost Analysis; D016572:Cyclosporine / Q000097:blood* / Q000191:economics / Q000493:pharmacokinetics / Q000627:therapeutic use; D003661:Decision Support Techniques; D004359:Drug Therapy, Combination; D004655:Emulsions; D006084:Graft Rejection / Q000517:prevention & control*; D006085:Graft Survival / Q000187:drug effects / Q000276:immunology; D006801:Humans; D007166:Immunosuppressive Agents / Q000097:blood / Q000191:economics / Q000493:pharmacokinetics / Q000627:therapeutic use; D016030:Kidney Transplantation / Q000276:immunology*; D009173:Mycophenolic Acid / Q000031:analogs & derivatives / Q000627:therapeutic use; D013997:Time Factors
D004655:Emulsions; D007166:Immunosuppressive Agents; D016572:Cyclosporine; D009173:Mycophenolic Acid; D001379:Azathioprine