Cost-effectiveness of salmeterol xinafoate/fluticasone propionate combination inhaler in chronic asthma

Objective: To determine where in the treatment steps recommended by the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) Asthma Guideline it is cost-effective to use salmeterol xinafoate/fluticasone propionate combination inhaler (SFC) (Seretide*) compared with other inhaled corticosteroid (ICS) containing regimens (with and without a long acting beta-2 agonist (LABA)) for chronic asthma in adults and children.

Research design and methods: Meta-analyses of percentage symptom-free days (%SFD) were used within a cost-effectiveness model. Time spent in two asthma control health states, 'symptom-free' and 'with-symptoms' was used as the measure of differential treatment effectiveness. SFC was compared with varying doses of fluticasone propionate (FP) and beclometasone dipropionate (BDP) with or without a separate salmeterol inhaler, and with the budesonicle/formoterol combination inhaler (BUD/FORM) (Symbicort dagger). Drug costs, non-drug costs and quality adjusted life years (QALY) were incorporated into the analyses.

Results are presented as cost per QALY ratios and uncertainty explored using probabilistic sensitivity analysis. Results: Compared with an increased dose of FP in adults, SFC either 'dominates' (i.e. cheaper and more effective) FP or the cost per QALY is 6852 pound. The cost per QALYs estimated in sensitivity analyses using BDP costs range from 5679 pound to 15997 pound. For children the cost per QALY for SFC 50 Evohaler* compared with an increased dose of FP is 15739 pound. SFC is similarly clinically effective in improving %SFDs compared with FP plus salmeterol delivered in separate inhalers (mean differences for each dose comparison of -3.9 (low) (with a 95% confidence interval (Cl): -12.96; 5.16); 4.10 (medium) (95% Cl: -3.01; 11.21); -0.4 (high) (95% Cl: -8.88; 8.08)) and BUD/FORM (mean difference of 0.40 (95% Cl -3.69; 4.49)) in adults, and a cheaper SFC option is available at all doses (annual cost savings range from 18- pound 427 pound per patient). SFC was similarly effective compared with FP plus salmeterol in separate inhalers in children under 12 and also resulted in annual cost savings of between 47 pound and 77 pound. A number of other comparisons were also made and the results are available as electronic supplementary data.

Conclusions: This is the first analysis to estimate the cost-effectiveness of SFC in chronic asthma compared with multiple comparators and based on a systematic identification of relevant trials and data on %SFDs. The findings suggest that for adults and children uncontrolled on BDP 400 mu g/day or equivalent it is a cost-effective option to switch to SFC (at an equivalent ICS dose) compared with increasing the dose of ICS. For adults and children aged 12 years and over who have passed this point and are uncontrolled on BDP 800 mu g/day or equivalent, switching to SFC remains a cost-effective approach. Where an adult or child requires an ICS and a LABA to be co-prescribed, SFC is a cost-effective option compared with FP or BDP plus salmeterol delivered in separate inhalers. In adults who require combination therapy, SFC is a cost-effective option compared with BUD/FORM.