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Rheumatology Advance Access published online on August 9, 2006
Rheumatology, doi:10.1093/rheumatology/kel249
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© The Author 2006. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Received March 9, 2006
Accepted June 1, 2006

Original Papers

Individual fracture risk and the cost-effectiveness of bisphosphonates in patients using oral glucocorticoids

T. P. van Staa 1, P. Geusens 2, B. Zhang 3, H. G. M. Leufkens 4, A. Boonen 5, and C. Cooper 6 *

1 Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands; MRC Epidemiology Resource Centre, University of Southampton, Southampton, UK
2 Department of Rheumatology, University Hospital, Maastricht, The Netherlands; University Hasselt, Campus Diepenbeek, Belgium
3 Statistician consultant, USA
4 Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
5 Department of Rheumatology, University Hospital, Maastricht, The Netherlands
6 MRC Epidemiology Resource Centre, University of Southampton, Southampton, UK

* To whom correspondence should be addressed.
C. Cooper, E-mail: cc{at}mrc.soton.ac.uk


  Abstract

Objectives. There are few data on the cost-effectiveness of bisphosphonates with oral glucocorticoids (GCs). An individual patient-based pharmaco-economic model was developed.

Methods. Data were obtained from a cohort of oral GC users aged 40+ (n = 190 000) in the UK General Practice Research Database. Individualized fracture and mortality risks were calculated specific for age, sex, daily and cumulative GC dose, indication and other clinical risk factors. UK costs of medication and direct costs of fracture were obtained from National Institute for Clinical Excellence and used to estimate costs per quality-adjusted life-year (QALY) gained and fracture prevented for bisphosphonates in patients treated for 5 yrs with GCs.

Results. With the use of 5 mg GCs daily, the cost per one QALY gained with bisphosphonates was 41k UK pounds (95% confidence intervals 22-72k) in women aged <60 [men £40k (29-54k)], £17k (13-24k) in women aged 60-79 [men £43k (31-60k)], £5k (3-6k) in women aged 80+ [men £35k (25-46k)]. With 15 mg GC, these figures were £17k (14-21k), £13k (10-16k) and £15k (9-26k) in women and £22k (17-26k), £34 (23-53k) and £33k (27-42k) in men, respectively. When stratifying by overall fracture risk and life expectancy at the start of GC therapy, cost per QALY increased with decreasing life expectancy. Patients with rheumatoid arthritis had comparatively better cost-effectiveness, given higher fracture risk and better life expectancy.

Conclusions. The cost-effectiveness of bisphosphonates varied substantially. Bisphosphonates can be considered cost-effective in patients with higher fracture risks, such as elderly patients (with a life expectancy over 5 yrs), and younger patients with a fracture history, low body mass index, rheumatoid arthritis or using high GC doses.

Keywords: Glucocorticoids; Corticosteroids; Osteoporosis; Fracture; Iatrogenic disease; Cost-effectiveness.
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