title: Cost-effectiveness of duloxetine in chronic low back pain: a Quebec societal perspective.
abstract: METHODS
  Cost-effectiveness model from a Quebec societal perspective using meta-analyses of clinical trials.
  
  
  OBJECTIVE
  To evaluate the cost-effectiveness of duloxetine in chronic low back pain (CLBP) compared with other post-first-line oral medications.
  
  
  BACKGROUND
  Duloxetine has recently received a CLBP indication in Canada. The cost-effectiveness of duloxetine and other oral medications has not previously been evaluated for CLBP.
  
  
  METHODS
  A Markov model was created on the basis of the economic model documented in the 2008 osteoarthritis clinical guidelines of the National Institute for Health and Clinical Excellence. Treatment-specific utilities were estimated via a meta-analysis of CLBP clinical trials and a transfer-to-utility regression estimated from duloxetine CLBP trial data. Adverse event rates of comparator treatments were taken from the National Institute for Health and Clinical Excellence model or estimated by a meta-analysis of clinical trials in osteoarthritis using a maximum-likelihood simulation technique. Costs were developed primarily from Quebec and Ontario public sources as well as the published literature and expert opinion. The 6 comparators were celecoxib, naproxen, amitriptyline, pregabalin, hydromorphone, and oxycodone. Subgroup analyses and 1-way and probabilistic sensitivity analyses were performed.
  
  
  RESULTS
  In the base case, naproxen, celecoxib, and duloxetine were on the cost-effectiveness frontier, with naproxen the least expensive medication, celecoxib with an incremental cost-effectiveness ratio of $19,881, and duloxetine with an incremental cost-effectiveness ratio of $43,437. Other comparators were dominated. Key drivers included the rates of cardiovascular and gastrointestinal adverse events and proton pump inhibitor usage. In subgroup analysis, the incremental cost-effectiveness ratio for duloxetine fell to $21,567 for a population 65 years or older and to $18,726 for a population at higher risk of cardiovascular and gastrointestinal adverse events.
  
  
  CONCLUSIONS
  The model estimates that duloxetine is a moderately cost-effective treatment for CLBP, becoming more cost-effective for populations older than 65 years or at greater risk of cardiovascular and gastrointestinal events.
  
  
  METHODS
  1.
authors.affiliation: Medical Decision Modeling Inc., Indianapolis, IN 46268, USA. rwielage@mdm-inc.com
authors.forename: Ronald
authors.initials: R
authors.lastname: Wielage
authors.forename: Megha
authors.initials: M
authors.lastname: Bansal
authors.forename: Kinsley
authors.initials: K
authors.lastname: Wilson
authors.forename: Robert
authors.initials: R
authors.lastname: Klein
authors.forename: Michael
authors.initials: M
authors.lastname: Happich
mesh_terms: D000367:Age Factors; D000368:Aged; D000639:Amitriptyline / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D000700:Analgesics / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000139:chemically induced; D000068579:Celecoxib; D002908:Chronic Disease; D002986:Clinical Trials as Topic; D003362:Cost-Benefit Analysis; D000068736:Duloxetine Hydrochloride; D005767:Gastrointestinal Diseases / Q000139:chemically induced; D006801:Humans; D004091:Hydromorphone / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D017116:Low Back Pain / Q000188:drug therapy*; D008390:Markov Chains; D008875:Middle Aged; D018803:Models, Economic; D009288:Naproxen / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D009864:Ontario; D010003:Osteoarthritis / Q000188:drug therapy; D017063:Outcome Assessment, Health Care / Q000191:economics / Q000706:statistics & numerical data; D010098:Oxycodone / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D000069583:Pregabalin; D011720:Pyrazoles / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D019057:Quality-Adjusted Life Years; D011792:Quebec; D013449:Sulfonamides / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D013876:Thiophenes / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D005680:gamma-Aminobutyric Acid / Q000009:adverse effects / Q000031:analogs & derivatives / Q000191:economics / Q000627:therapeutic use
chemical_list: D000700:Analgesics; D011720:Pyrazoles; D013449:Sulfonamides; D013876:Thiophenes; D000639:Amitriptyline; D000069583:Pregabalin; D005680:gamma-Aminobutyric Acid; D009288:Naproxen; D000068736:Duloxetine Hydrochloride; D010098:Oxycodone; D000068579:Celecoxib; D004091:Hydromorphone