A new analysis finds that vonoprazan triple therapy (Voquezna) is the most cost-effective first-line regimen to eradicate Helicobacter pylori infection in the United States.
Rifabutin triple therapy (Talicia) is the second most cost-effective strategy for H pylori eradication, followed in order of decreasing cost-effectiveness by vonoprazan dual therapy, bismuth quadruple therapy, and clarithromycin triple therapy.
The analysis is believed to be the first to report on the cost-effectiveness of vonoprazan- and rifabutin-based regimens as first-line treatments for H pylori infection from the perspective of US healthcare payers.
The findings “strongly” suggest that vonoprazan triple therapy would provide the greatest net health benefit and monetary benefit for US payers, report Ismaeel Yunusa, PharmD, PhD, University of South Carolina College of Pharmacy in Columbia, and colleagues.
The study was published online this month in the American Journal of Gastroenterology.
It’s estimated that more than 114 million people in the United States have H pylori infection. Clinical practice guidelines recommend H pylori eradication in all patients with a positive test of active infection.
Using a Markov model, Yunusa and colleagues estimated the cost-effectiveness of five pre-packaged or co-formulated H pylori eradication regimens: clarithromycin triple therapy, bismuth quadruple therapy, vonoprazan dual therapy, vonoprazan triple therapy, and rifabutin triple therapy.
The model estimated the expected costs in 2022 US dollars, expected quality-adjusted life years (QALYs), incremental cost-effectiveness ratio (ICERs), and expected net monetary benefit over 20 years.
Among their key findings and conclusions:
Bismuth quadruple therapy had the highest expected cost ($1439) and rifabutin triple regimen had the lowest expected cost ($1048).
Because rifabutin triple therapy was predicted to cost less and was more effective than clarithromycin triple therapy, bismuth quadruple therapy, and vonoprazan dual therapy, it dominated all treatment strategies — except for vonoprazan triple therapy.
Compared with rifabutin triple therapy, vonoprazan triple therapy had a higher expected cost ($1172 vs $1048) and expected QALY (14.262 vs 14.256), yielding an ICER of $22,573 per QALY.
Vonoprazan triple therapy had the highest expected net monetary benefit and was the most cost-effective at willingness to pay thresholds between $50,000 and $150,000 per QALY, followed by rifabutin triple therapy.
Vonoprazan triple therapy would result on average in an incremental net benefit of $1655 per patient than clarithromycin triple therapy.
Because the rifabutin-based regimen was more cost-effective than all but vonoprazan triple therapy, it has a potential role as an alternative first-line treatment.
Rifabutin triple therapy and vonoprazan dual therapy would need to be considerably discounted (by 15%–43% and by 44%–85%, respectively), to be cost-effective at commonly used cost-effectiveness thresholds.
Vonoprazan dual therapy demonstrated limited value relative to other available options; thus, its widespread adoption as a first-line strategy seems unlikely.
Based on the results, it would be hard to justify the use of bismuth quadruple therapy or clarithromycin triple therapy since they provide the lowest net monetary benefit and have lower eradication rates.
The investigators note that their analysis considered only direct costs of therapy, not other costs such as appointments, travel, and time away from work.
They also assumed medical costs, including endoscopy and H pylori testing, would not change regardless of treatment regimen. Therefore, total healthcare costs may be underestimated.
The study did not receive any funding. The authors have declared no relevant financial relationships.
Am J Gastroenterol. Published online December 14, 2022. Abstract
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