Cost Effectiveness of Long-Term Incobotulinumtoxin-A Treatment in the Management of Post-stroke Spasticity of the Upper Limb from the Australian Payer Perspective.

BACKGROUND: In Australia, the reimbursement of botulinum neurotoxin-A (BoNT-A) on the Pharmaceutical Benefits Scheme for the treatment of moderate to severe spasticity of the upper limb following a stroke (PSS-UL) is restricted to four treatment cycles per upper limb per lifetime. This analysis examined the cost effectiveness of extending the treatment beyond four treatments among patients with an adequate response to previous treatment cycles. METHODS: A Markov state transition model was developed to perform a cost-utility analysis of extending the use of incobotulinumtoxin-A beyond the current restriction of four treatment cycles among patients who have shown a successful response in previous treatment cycles ('known responders'). The Markov model followed patients in 12-weekly cycles for 5 years, estimating the proportion of patients with or without response over this period in each of the modelled treatment arms. Post hoc analysis of an open-label extension phase study informed the Markov model. The perspective of the analysis was the Australian healthcare system, meaning only direct healthcare costs were included. Utility values by response status were derived from EQ-5D data from a published double-blind, placebo-controlled study. The primary outcome measure was the incremental cost per quality-adjusted life-year (QALY). Univariate and probabilistic sensitivity analyses were conducted. RESULTS: The open-label extension study data demonstrated the probability of treatment response after four injections was greater among 'known responders' than those without prior response. The incremental cost per QALY gained of continued use of incobotulinumtoxin-A beyond the current restriction of four treatments was A$59,911. CONCLUSION: Limiting BoNT-A treatment to four cycles per patient per lifetime is likely to be suboptimal in many patients with PSS-UL. Treatment response beyond four cycles is highest among known responders, and allowing such patients to continue treatment beyond four cycles appears cost effective.

Quality of life impairment, disability and economic burden associated with chronic daily headache, focusing on chronic migraine with or without medication overuse: a systematic review.

OBJECTIVE: To evaluate the evidence for quality of life (QoL) impairment, disability, healthcare resource use and economic burden associated with chronic daily headache (CDH), focusing on chronic migraine (CM) with or without medication overuse. METHODS: A systematic review and qualitative synthesis of studies of patients/subjects with CDH that included CM, occurring on at least 15 days per month. MAIN FINDINGS: Thirty-four studies were included for review (25 studies of patients and nine of subjects from the general population). CDH and CDH with medication overuse headache (MOH) were consistently associated with a lower QoL compared to control or episodic headache (EH) and CDH without MOH. CDH was consistently associated with greater disability and productivity loss, more consultations, more or longer hospitalizations and higher direct costs than EH. Data were not amenable to statistical pooling. PRINCIPAL CONCLUSIONS: The findings of this review underline the detriment to QoL and the disabling nature of CDH, and in particular CM and CDH with MOH, and negative impact on workplace productivity compared to other types of headache.

A comparison of olanzapine versus risperidone for the treatment of schizophrenia: a meta-analysis of randomised clinical trials.

Objective This meta-analysis was carried out to compare the efficacy and safety of olanzapine with risperidone in the treatment of schizophrenia. Methods Data from randomised, double-blind studies were analysed according to short- (≤12 weeks) and longer-term (>12 weeks) treatment, and included all-doses analyses and a sensitivity analysis of clinically relevant doses. A range of efficacy and safety parameters was measured. Results Olanzapine produced statistically significant improvements in efficacy and safety parameters compared with risperidone over both the short and longer term. Anticholinergic use, study dropouts, changes in Positive and Negative Syndrome Scale and Brief Psychiatric Rating Scale scores, and Quality-of-Life Scale changes, were often significantly in favour of olanzapine. Results from the sensitivity analyses of only clinically relevant doses further favoured olanzapine compared with the all-doses analyses. Conclusion Small changes in the presence or severity of psychotic symptoms and side-effects can affect a patient's prognosis and quality of life. With this in mind, the efficacy and safety advantages of olanzapine suggested by this study may convey clinical relevance to certain aspects of schizophrenia. However, further research - especially into longer-term efficacy and safety - is needed to confirm the differences between the available antipsychotics.