title: The cost effectiveness of licensed oromucosal midazolam (Buccolam(®)) for the treatment of children experiencing acute epileptic seizures: an approach when trial evidence is limited.
abstract: BACKGROUND
  In the UK, two treatment options are used for acute epileptic seizures in the community-rectal diazepam and unlicensed buccal midazolam. In practice, the former is rarely used, with unlicensed buccal midazolam being widely recommended and prescribed by physicians. In September 2011, Buccolam(®) (licensed midazolam oromucosal solution) became the first medicine to receive a Paediatric-Use Marketing Authorization (PUMA) and it is indicated for the treatment of prolonged, acute, convulsive seizures by caregivers in the community for children (aged 6 months to <18 years) diagnosed with epilepsy. The approval process for a PUMA product differs from other marketing authorization processes and may be based upon small population subsets and may not, in some cases, require new safety or efficacy data to be generated; a similar situation to that seen for orphan drugs. This can lead to challenges when conducting economic evaluations.
  
  
  OBJECTIVE
  The aim of this study was to assess the cost effectiveness of Buccolam(®) for children with a diagnosis of epilepsy suffering prolonged, acute, convulsive seizures occurring in the UK community setting. DESIGN AND PERSPECTIVE: A hybrid model was developed according to a UK payer perspective. The model included a time-to-event simulation for the frequency and location of occurrence of seizures, along with a decision-tree model that assessed the treatment pathway when a seizure occured. The model compared treatment with Buccolam(®) with standard care in the community (95 % unlicensed buccal midazolam and 5 % rectal diazepam) or either treatment alone. The model was informed by data from a variety of sources, including clinical effectiveness estimates, and costs based on published UK data, using 2012-13 prices, where possible. To determine current practice and real-world effectiveness, a Delphi panel and a survey of parents of children with epilepsy were conducted.
  
  
  RESULTS
  Buccolam(®) showed a reduction in costs of £2,939 compared with standard care, £14,269 compared with rectal diazepam alone and £886 compared with unlicensed buccal midazolam alone. Increases of 0.025, 0.082 and 0.013 quality-adjusted life-years, respectively, were also seen. Buccolam(®) remained dominant across a range of scenario analyses.
  
  
  CONCLUSIONS
  This model demonstrates the possibility of constructing a thorough economic case when trial or real-world data are not available. The results of the model show Buccolam(®) to be cost saving compared with rectal diazepam due to a reduction in the need for ambulance callouts and hospital stays, and compared with unlicensed buccal midazolam, through reduced drug costs and wastage.
authors.affiliation: BresMed, North Church House, 84 Queen Street, Sheffield, S1 2DW, UK. dlee@bresmed.co.uk
authors.forename: Dawn
authors.initials: D
authors.lastname: Lee
authors.forename: Daniel
authors.initials: D
authors.lastname: Gladwell
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Batty
authors.forename: Nic
authors.initials: N
authors.lastname: Brereton
authors.forename: Elaine
authors.initials: E
authors.lastname: Tate
mesh_terms: D000208:Acute Disease; D000278:Administration, Buccal; D000285:Administration, Rectal; D002648:Child; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D003975:Diazepam / Q000191:economics* / Q000627:therapeutic use; D017277:Drug Approval; D004827:Epilepsy / Q000188:drug therapy* / Q000191:economics; D017048:Health Care Costs; D006801:Humans; D008874:Midazolam / Q000191:economics* / Q000627:therapeutic use; D011788:Quality of Life; D059039:Standard of Care / Q000191:economics*; D006113:United Kingdom
chemical_list: D003975:Diazepam; D008874:Midazolam