A Health Economic Analysis of Non-injectable Epinephrine Compared with Intramuscular Epinephrine

Abstract

BackgroundNon-injectable epinephrine to treat allergic reactions addresses an unmet need. Intranasal epinephrine is approved and a sublingual form is under development. Inhaled epinephrine is poorly studied for anaphylaxis. These forms have unknown cost-effectiveness. ObjectiveThe aim of this research was to evaluate cost-effectiveness of commercially available non-injectable epinephrine compared with intramuscular epinephrine for treatment of anaphylaxis. MethodsMarkov cohort analyses evaluated the cost-effectiveness of non-injectable epinephrine forms. The base-case assumed exaggerated anaphylaxis fatality rates (50-fold increase) for using inhaled epinephrine given low certainty evidence in anaphylaxis, and deliberately reduced fatality risk for nasal or sublingual forms (10-fold reduction) theorizing higher adherence and early use during an allergic reaction. ResultsIn the base-case scenario, assuming a 10-fold decreased risk in peanut allergy fatality associated with intranasal or sublingual epinephrine treatment for a severe allergic reaction (net monetary benefit [NMB] $2,189,134) vs. intramuscular (IM) epinephrine use (NMB, 2,189,114), intranasal or sublingual epinephrine was the most cost-effective option (incremental cost-effectiveness ratio [ICER] $83,748/QALY), but only at a marginal annual cost of $4. IM epinephrine was cost-effective (ICER, $17,900/QALY) vs. inhaled epinephrine (NMB, $2,183,531), although inhaled epinephrine reached cost-effectiveness (Willingness To Pay [WTP $100,000/QALY]) if associated fatality risk fell below 2.5-fold. Substituting a single non-injectable form of epinephrine for a second injectable device (in patients prescribed two autoinjectors already) would be cost-effective; however, adding a supplemental non-injectable device was not cost-effective, even assuming a 10-fold risk reduction with multiple device carriage (ICER $858,462). ConclusionNon-injectable routes of epinephrine can be cost-effective options provided fatality risk is not significantly elevated. Carriage of redundant epinephrine autoinjectors with non-injectable forms is not cost-effective if associated with excess cost of redundant device packs.