title: Impact of non-traditional phosphate binders and cinacalcet on haemodialysis patient biochemistry, pill burden and cost.
abstract: OBJECTIVE
  The Australian Pharmaceutical Benefits Scheme (PBS) commenced cost subsidization for haemodialysis patients of sevelamer in December 2007, cinacalcet in July 2008 and lanthanum in May 2009. To determine the impact of PBS listing of these medications, we performed a single centre cross-sectional, longitudinal study.
  
  
  METHODS
  Dialysis parameters and biochemistry were prospectively collected at 6 monthly intervals for all prevalent haemodialysis patients from October 2007 to April 2010. Medications prescribed to manage chronic kidney disease mineral and bone disorder were recorded. Univariate regression analysis was undertaken for each variable against time.
  
  
  RESULTS
  Patient numbers ranged from 87 to 114 in each period. At baseline, mean age was 68.8 ± 14.3 years, 71% male, 15.1 ± 3.5 haemodialysis hours/week and urea reduction ratio 71.9 ± 9.8%. These variables were unchanged over time. The use of sevelamer, cinacalcet and lanthanum increased (P < 0.001). There was a decrease in the use of aluminium- and calcium-based phosphate binders (P < 0.001) but no change in the use of magnesium based phosphate binders (P = 0.09) or calcitriol (P = 0.11). Serum phosphate (P = 0.13) and parathyroid hormone (PTH) (P = 0.87) were unchanged. Mean 'bone pill' burden fell from 60.3/week to 51.9/week (P = 0.02). Mean pill cost increased from Australian dollars (AUD) 12.85/patient per week to AUD 59.85/patient per week (P < 0.001).
  
  
  CONCLUSIONS
  The PBS subsidization of sevelamer, cinacalcet and lanthanum has changed prescribing patterns, although serum phosphate and PTH remain unchanged. These changes have been at an additional cost of AUD 2444/patient per year. Data to address clinical end-points of mortality and hospitalization is needed to determine if the cost of these newer agents is warranted.
authors.affiliation: Department of Renal Medicine, Nambour General Hospital The University of Queensland, Australia. nicholas_gray@health.qld.gov.au
authors.forename: Nicholas A
authors.initials: NA
authors.lastname: Gray
authors.forename: Rathika
authors.initials: R
authors.lastname: Krishnasamy
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Vardesh
authors.forename: Peter R
authors.initials: PR
authors.lastname: Hollett
authors.forename: Chris M
authors.initials: CM
authors.lastname: Anstey
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D000536:Aluminum Hydroxide / Q000191:economics / Q000627:therapeutic use; D001315:Australia / Q000453:epidemiology; D002117:Calcitriol / Q000378:metabolism; D002119:Calcium Carbonate / Q000191:economics / Q000627:therapeutic use; D002614:Chelating Agents / Q000191:economics / Q000627:therapeutic use; D000069449:Cinacalcet; D016527:Drug Costs / Q000706:statistics & numerical data*; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006436:Hemodialysis Units, Hospital / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D007676:Kidney Failure, Chronic / Q000188:drug therapy* / Q000191:economics* / Q000378:metabolism; D007811:Lanthanum / Q000191:economics / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009281:Naphthalenes / Q000191:economics* / Q000627:therapeutic use; D010281:Parathyroid Hormone / Q000378:metabolism; D010710:Phosphates / Q000378:metabolism; D011073:Polyamines / Q000191:economics* / Q000627:therapeutic use; D006435:Renal Dialysis / Q000191:economics*; D000069603:Sevelamer
chemical_list: D002614:Chelating Agents; D009281:Naphthalenes; D010281:Parathyroid Hormone; D010710:Phosphates; D011073:Polyamines; D000536:Aluminum Hydroxide; D007811:Lanthanum; D000069603:Sevelamer; D002117:Calcitriol; D002119:Calcium Carbonate; D000069449:Cinacalcet