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Cost-Effectiveness of Duloxetine in Chronic Low Back Pain: A Quebec Societal Perspective

Wielage, Ronald MPH*; Bansal, Megha MA*; Wilson, Kinsley PhD; Klein, Robert MS*; Happich, Michael PhD

doi: 10.1097/BRS.0b013e31828264f9
Health Services Research

Study Design. Cost-effectiveness model from a Quebec societal perspective using meta-analyses of clinical trials.

Objective. To evaluate the cost-effectiveness of duloxetine in chronic low back pain (CLBP) compared with other post–first-line oral medications.

Summary of Background Data. Duloxetine has recently received a CLBP indication in Canada. The cost-effectiveness of duloxetine and other oral medications has not previously been evaluated for CLBP.

Methods. A Markov model was created on the basis of the economic model documented in the 2008 osteoarthritis clinical guidelines of the National Institute for Health and Clinical Excellence. Treatment-specific utilities were estimated via a meta-analysis of CLBP clinical trials and a transfer-to-utility regression estimated from duloxetine CLBP trial data. Adverse event rates of comparator treatments were taken from the National Institute for Health and Clinical Excellence model or estimated by a meta-analysis of clinical trials in osteoarthritis using a maximum-likelihood simulation technique. Costs were developed primarily from Quebec and Ontario public sources as well as the published literature and expert opinion. The 6 comparators were celecoxib, naproxen, amitriptyline, pregabalin, hydromorphone, and oxycodone. Subgroup analyses and 1-way and probabilistic sensitivity analyses were performed.

Results. In the base case, naproxen, celecoxib, and duloxetine were on the cost-effectiveness frontier, with naproxen the least expensive medication, celecoxib with an incremental cost-effectiveness ratio of $19,881, and duloxetine with an incremental cost-effectiveness ratio of $43,437. Other comparators were dominated. Key drivers included the rates of cardiovascular and gastrointestinal adverse events and proton pump inhibitor usage. In subgroup analysis, the incremental cost-effectiveness ratio for duloxetine fell to $21,567 for a population 65 years or older and to $18,726 for a population at higher risk of cardiovascular and gastrointestinal adverse events.

Conclusion. The model estimates that duloxetine is a moderately cost-effective treatment for CLBP, becoming more cost-effective for populations older than 65 years or at greater risk of cardiovascular and gastrointestinal events.

Level of Evidence: 1

A Quebec Markov model-based cost-utility analysis comparing duloxetine with other post-first-line oral treatments in chronic low back pain estimated a cost per quality-adjusted life year of $43,437 in the base case population, with incremental cost-effectiveness ratios of $21,567 and $18,726, respectively, in subgroups older than 65 years or at higher risk of nonsteroidal anti-inflammatory drug-related adverse events.

From *Medical Decision Modeling Inc., Indianapolis, IN

Eli Lilly Canada, Toronto, Ontario; and

Lilly Deutschland GmbH, Bad Homburg, Germany.

Address correspondence and reprint requests to Ronald Wielage, MPH, Medical Decision Modeling Inc., 8909 Purdue Rd., Ste. 550, Indianapolis, IN 46268; E-mail:

Acknowledgment date: June 14, 2012. First revision date: November 30, 2012. Acceptance date: December 6, 2012.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

Eli Lilly and Company funds were received to support this work.

Relevant financial activities outside the submitted work: employment, consultancy, stock/stock options, and royalties.

© 2013 by Lippincott Williams & Wilkins