Cost-effectiveness of angiotensin-converting enzyme inhibitors versus angiotensin II receptor blockers as first-line treatment in autosomal dominant polycystic kidney disease.
BACKGROUND
Autosomal dominant polycystic kidney disease (ADPKD) is a rare kidney disorder impacting ∼1:2,500 individuals among the general US population. Hypertension is a significant predictor of ADPKD progression, and a risk factor for development of cardiovascular disease (CVD), the most common cause for mortality among ADPKD patients. Angiotensin-converting enzymes inhibitors (ACE-I) are widely used as first-line treatment in ADPKD for the management of hypertension. However, their cost-effectiveness relative to other hypertensive medications, such as angiotensin II receptor blockers (ARB), has never been assessed.


OBJECTIVE
To determine if ARB are more cost-effective than ACE-Is as first-line treatment in ADPKD.


METHODS
A Markov-state decision model was constructed for estimation of cost and outcome benefits in hypertensive ADPKD patients. Transition probabilities were extrapolated from a retrospective cohort study comparing chronic kidney disease (CKD) stage transitions in ADPKD patients. Annual pharmaceutical costs per average daily dose per CKD stage were extracted from a US healthcare claims database. Median total healthcare costs per CKD stage or transplant were extracted from the published literature. The time horizon was set to 30 years, with 1-year duration to cycle shift. A cost-effectiveness analysis was conducted to estimate the incremental cost-effectiveness ratio (ICER) of ACE-I vs ARB per additional year of prevented transplant and/or death. A one-way probabilistic sensitivity analysis was conducted, with 10% variation in probabilities and cost.


RESULTS
Total annual healthcare costs accrued after 30 years among ADPKD patients taking ACE-Is was estimated to be $3,505,028.41, compared to ARB at $3,644,327.65. Life expectancy was increased by 1.39 years among patients taking ACE-I. Approximate 10-year survival in patients taking ACE-Is was 47% compared to ARB at 34%.


CONCLUSIONS
ACE-I dominated ARB and displayed greater cost-effectiveness due to lower cost and increased capacity to prolong years of life without transplant or death among hypertensive ADPKD patients. This model strengthens the value of ACE-I over ARB as first-line treatment for hypertension management in ADPKD patients.
a University of North Carolina at Charlotte , NC , USA.
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Clark
a University of North Carolina at Charlotte , NC , USA.|b Precision Health Economics , Davidson , NC , USA.
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Whitmire
a University of North Carolina at Charlotte , NC , USA.
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Patton
a University of North Carolina at Charlotte , NC , USA.
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Clark
a University of North Carolina at Charlotte , NC , USA.|b Precision Health Economics , Davidson , NC , USA.
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Blanchette
a University of North Carolina at Charlotte , NC , USA.
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Howden
D057911:Angiotensin Receptor Antagonists / Q000191:economics* / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000191:economics* / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D018450:Disease Progression; D005252:Fees, Pharmaceutical / Q000706:statistics & numerical data; D005919:Glomerular Filtration Rate; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000188:drug therapy*; D007345:Insurance Claim Review / Q000706:statistics & numerical data; D008390:Markov Chains; D018803:Models, Economic; D016891:Polycystic Kidney, Autosomal Dominant / Q000150:complications / Q000188:drug therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D014481:United States
D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors
Autosomal dominant polycystic kidney disease; Chronic kidney disease; End-stage renal disease; Healthcare costs; Hypertension; Incremental cost-effectiveness ratio; Mortality; Renal transplant