title: Sequential medication strategies for postherpetic neuralgia: a cost-effectiveness analysis.
abstract: Several medications are recommended for relief of postherpetic neuralgia (PHN). A sequential treatment algorithm has been suggested, but its cost-effectiveness is unclear. We developed a decision model to estimate the cost-effectiveness of this algorithm compared with other sequential medication strategies in 70-year-olds with PHN, using literature data to model medication-related PHN relief while also accounting for severe medication side effects. Hypothetical patients with and without coronary artery disease (CAD) were considered separately, with and without localized pain. Sequential medication switches occurred as the result of inadequate relief or intolerable side effects. Probabilistic sensitivity analyses were performed to estimate the favorability of each medication early in treatment sequences. In patients without CAD, tricyclic and gabapentin were equally favored as initial therapy if mortality with tricyclic use was not increased, but gabapentin was strongly favored if it was. In patients with CAD, gabapentin was overwhelmingly favored. In either patient group, opioids, pregabalin, and tramadol were not favored as initial therapy but were sensible choices later in treatment sequences. The lidocaine patch was a reasonable first choice in patients with localized PHN. Our analysis supports the suggested treatment algorithm, with cost-effectiveness ratios within acceptable ranges for medications given sequentially, based on literature-based estimates of effectiveness and tolerability.
  
  
  CONCLUSIONS
  This article examines the cost-effectiveness of recommended sequential treatment strategies for postherpetic neuralgia. This decision analysis-based synthesis of effectiveness and cost data found that recommended treatment algorithms are also economically reasonable.
authors.affiliation: Section of Decision Sciences and Clinical Systems Modeling, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA. smithkj2@upmc.edu
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Smith
authors.forename: Mark S
authors.initials: MS
authors.lastname: Roberts
mesh_terms: D000368:Aged; D000465:Algorithms; D000700:Analgesics / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D002986:Clinical Trials as Topic; D015331:Cohort Studies; D003324:Coronary Artery Disease / Q000150:complications / Q000188:drug therapy; D003362:Cost-Benefit Analysis; D006801:Humans; D008954:Models, Biological; D051474:Neuralgia, Postherpetic / Q000188:drug therapy* / Q000191:economics*; D012196:Review Literature as Topic
chemical_list: D000700:Analgesics