Cost-effectiveness of inhaled steroids in asthma: impact of effect on bone mineral density.
BACKGROUND
The effects of inhaled corticosteroid (ICS) preparations on bone health have been debated. Multiple analyses have been published examining the question, with mixed results.


OBJECTIVE
We examined how assumptions about the effect of ICS on bone mineral density (BMD) influence the cost-effectiveness of ICS in asthma.


METHODS
We developed a mathematical simulation model to estimate clinical outcomes and costs for a cohort with mild/moderate asthma. The analysis conformed to reference case recommendations of the US Panel on Cost-Effectiveness in Health and Medicine. Sensitivity analysis evaluated the stability of our results to uncertainty in treatment duration, age at treatment, and ICS dose.


RESULTS
Assuming a dose of 200 microg twice per day of ICS, a literature-based average effect of ICS on BMD and a 10-year time horizon, we observed a minimal increase in the costs attributed to hip fracture and incremental cost effectiveness ratio of $26,000 per quality-adjusted life-year and $14.00 per symptom-free day gained. Over an extended the time horizon (lifetime), the incremental cost effectiveness ratio increased to $42,000/quality-adjusted life-year. Only under a scenario of high-dose ICS, a lifetime horizon, and a large effect of ICS on BMD did the potential impact of ICS on BMD dramatically affect the economic attractiveness of therapy.


CONCLUSIONS
To minimize any potential impact, use of the lowest effective dose of ICS and measures to target and intervene in high-risk individuals are warranted. However, ICS therapy in mild/moderate asthma compares favorably with commonly accepted interventions over a wide range of assumptions regarding this treatment and its effects on BMD.
Fuhlbrigge
Anne L
AL
Channing Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA. anne.fuhlbrigge@channing.harvard.edu
Bae
Seung Jin
SJ
Weiss
Scott T
ST
Kuntz
Karen M
KM
Paltiel
A David
AD
D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D000368:Aged; D001249:Asthma / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D015519:Bone Density / Q000187:drug effects*; D003362:Cost-Benefit Analysis; D005260:Female; D006620:Hip Fractures; D006801:Humans; D008390:Markov Chains; D008875:Middle Aged; D008962:Models, Theoretical; D019057:Quality-Adjusted Life Years; D016896:Treatment Outcome
D000305:Adrenal Cortex Hormones