title: Cost-effectiveness of tiotropium versus glycopyrronium in moderate to very severe chronic obstructive pulmonary disease in Canada, Spain, Sweden, and the UK.
abstract: OBJECTIVE
  Tiotropium (TIO), Spiriva® Handihaler®, is a well-established bronchodilator, LAMA (long acting muscarinic antagonist), for the treatment of moderate to very severe chronic obstructive pulmonary disease (COPD). Clinical evidence from the SPARK trial suggests that TIO is superior to glycopyrronium (GLY), Seebri® Breezhaler®, in terms of severe exacerbations. This modeling study assessed the cost-effectiveness of TIO versus GLY for Canada (CAN), Spain (ESP), Sweden (SWE), and the UK, making use of this new clinical evidence.
  
  
  METHODS
  A Markov cohort model, with moderate to very severe (Global Initiative for Chronic Obstructive Lung Disease II-IV) COPD patients, was populated with efficacy data from the Understanding Potential Long-term Impacts on Function with Tiotropium (UPLIFT) and SPARK trials as well as costs, utilities, and epidemiological data relevant for each country. Treatment efficacy was modeled as improvements in lung function, quality-adjusted life years (QALYs), and as a lowering of the risk of exacerbations (rate of exacerbations). Risks of exacerbations differed between cohorts based on data from SPARK. Health and cost outcomes were simulated over an approximate lifetime horizon, starting from the age of 65 years. Robustness of results was validated in deterministic sensitivity analyses.
  
  
  RESULTS
  Over the lifetime horizon, patients treated with TIO accumulated -623 (CAN), 1,066 (ESP), 1,137 (SWE), and -169 (UK), respectively, in incremental costs (€2014). TIO generated better health outcomes compared to GLY in all countries, 0.21 (CAN), 0.25 (ESP), 0.23 (SWE), and 0.23 (UK) in incremental QALYs. The cost per QALY gained was found to be €4,281 and €1,137 for ESP and SWE, respectively, while TIO was found to be cost saving in CAN and the UK. The results were mainly driven by the relative risk of severe exacerbations found in SPARK (GLY/TIO relative risk: 1.43, 95% confidence interval: 1.05-1.97, P=0.025).
  
  
  CONCLUSIONS
  The results from this study show that TIO is a cost-effective treatment compared to GLY in moderate to very severe COPD. The cost per QALY is well below the existing implicit and explicit willingness-to-pay thresholds.
authors.affiliation: Quantify Research AB, Stockholm, Sweden.
authors.forename: Oskar
authors.initials: O
authors.lastname: Eklund
authors.affiliation: Boehringer Ingelheim, Asker, Norway.
authors.forename: Faraz
authors.initials: F
authors.lastname: Afzal
authors.affiliation: Quantify Research AB, Stockholm, Sweden.
authors.forename: Fredrik
authors.initials: F
authors.lastname: Borgström
authors.affiliation: Boehringer Ingelheim, Burlington, ON, Canada.
authors.forename: Jason
authors.initials: J
authors.lastname: Flavin
authors.affiliation: Boehringer Ingelheim, Bracknell, Berkshire, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Ternouth
authors.affiliation: Boehringer Ingelheim, Sant Cugat del Vallès, Barcelona, Spain.
authors.forename: Maria Eugenia
authors.initials: ME
authors.lastname: Ojanguren
authors.affiliation: Boehringer Ingelheim, Sant Cugat del Vallès, Barcelona, Spain.
authors.forename: Carlos
authors.initials: C
authors.lastname: Crespo
authors.affiliation: Boehringer Ingelheim, Ingelheim, Germany.
authors.forename: Mike
authors.initials: M
authors.lastname: Baldwin
keywords: COPD; Markov cohort model; cost-effectiveness; exacerbations; glycopyrronium; tiotropium