title: The cost-effectiveness of duloxetine in chronic low back pain: a US private payer perspective.
abstract: OBJECTIVE
  To assess the cost-effectiveness of duloxetine in the treatment of chronic low back pain (CLBP) from a US private payer perspective.
  
  
  METHODS
  A cost-utility analysis was undertaken for duloxetine and seven oral post-first-line comparators, including nonsteroidal anti-inflammatory drugs (NSAIDs), weak and strong opioids, and an anticonvulsant. We created a Markov model on the basis of the National Institute for Health and Clinical Excellence model documented in its 2008 osteoarthritis clinical guidelines. Health states included treatment, death, and 12 states associated with serious adverse events (AEs). We estimated treatment-specific utilities by carrying out a meta-analysis of pain scores from CLBP clinical trials and developing a transfer-to-utility equation using duloxetine CLBP patient-level data. Probabilities of AEs were taken from the National Institute for Health and Clinical Excellence model or estimated from osteoarthritis clinical trials by using a novel maximum-likelihood simulation technique. Costs were gathered from Red Book, Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project database, the literature, and, for a limited number of inputs, expert opinion. The model performed one-way and probabilistic sensitivity analyses and generated incremental cost-effectiveness ratios (ICERs) and cost acceptability curves.
  
  
  RESULTS
  The model estimated an ICER of $59,473 for duloxetine over naproxen. ICERs under $30,000 were estimated for duloxetine over non-NSAIDs, with duloxetine dominating all strong opioids. In subpopulations at a higher risk of NSAID-related AEs, the ICER over naproxen was $33,105 or lower.
  
  
  CONCLUSIONS
  Duloxetine appears to be a cost-effective post-first-line treatment for CLBP compared with all but generic NSAIDs. In subpopulations at risk of NSAID-related AEs, it is particularly cost-effective.
authors.affiliation: Medical Decision Modeling Inc., Indianapolis, IN 46268, USA. rwielage@mdm-inc.com
authors.forename: Ronald C
authors.initials: RC
authors.lastname: Wielage
authors.forename: Megha
authors.initials: M
authors.lastname: Bansal
authors.forename: J Scott
authors.initials: JS
authors.lastname: Andrews
authors.forename: Madelaine M
authors.initials: MM
authors.lastname: Wohlreich
authors.forename: Robert W
authors.initials: RW
authors.lastname: Klein
authors.forename: Michael
authors.initials: M
authors.lastname: Happich
mesh_terms: D000701:Analgesics, Opioid / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use; D000927:Anticonvulsants / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use; D002908:Chronic Disease; D003362:Cost-Benefit Analysis; D000068736:Duloxetine Hydrochloride; D017850:Economics, Pharmaceutical; D006801:Humans; D007348:Insurance, Health / Q000191:economics*; D017116:Low Back Pain / Q000188:drug therapy / Q000191:economics*; D008390:Markov Chains; D015201:Meta-Analysis as Topic; D018803:Models, Economic; D019057:Quality-Adjusted Life Years; D017367:Selective Serotonin Reuptake Inhibitors / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use; D013876:Thiophenes / Q000191:economics* / Q000627:therapeutic use; D014481:United States
chemical_list: D000701:Analgesics, Opioid; D000894:Anti-Inflammatory Agents, Non-Steroidal; D000927:Anticonvulsants; D000068736:Duloxetine Hydrochloride; D017367:Selective Serotonin Reuptake Inhibitors; D013876:Thiophenes