Abstract
BackgroundUncontrolled hyperphosphatemia in chronic kidney disease (CKD) patients commonly results in vascular calcification leading to increased risk of cardiovascular disease. Phosphate binders (PBs) are used for hyperphosphatemia and can be calcium-based (CBPBs) or non-calcium-based (NCBPBs), the latter being more expensive than CBPBs. In this study, we used meta-analysis approaches to assess the cost-utility of PBs for hyperphosphatemia in CKD patients.MethodsRelevant studies published prior to June 2019 were identified from PubMed, Scopus, the Cochrane Library, the National Health Service Economic Evaluation Database, and the Cost-Effectiveness Analysis Registry. Studies were eligible if they included CKD patients with hyperphosphatemia, compared any PBs and reported economic outcomes. Meta-analysis was applied to pool incremental net benefit (INB) across studies stratified by country income.ResultsA total of 25 studies encompassing 32 comparisons were eligible. Lanthanum carbonate, a NCBPB, was a more cost-effective option than CBPBs in high-income countries (HICs), with a pooled INB of $3984.4 (599.5–7369.4), especially in pre-dialysis patients and used as a second-line option with INBs of $4860.2 (641.5–9078.8), $4011.0 (533.7–7488.3), respectively. Sevelamer, also a NCBPB, was not more cost-effective as a first-line option compared to CBPBs with a pooled INB of $6045.8 (− 23,453.0 to 35,522.6) and $34,168.9 (− 638.0 to 68,975.7) in HICs and upper middle-income countries, respectively.ConclusionsLanthanum carbonate was significantly more cost-effective than CBPBs as a second-line option for hyperphosphatemia in pre-dialysis patients in HICs. However, the use of sevelamer is not more cost-effective as a first-line option compared to CBPBs.
Highlights
MethodsChronic kidney disease (CKD) represents a significant global public health burden with high economic costs related to morbidity and mortality [1]
All Cost-Effectiveness Analysis (CEA) studies were from high-income countries (HICs) with sevelamer versus calcium-based PBs (CBPBs) (N = 5 [67,68,69,70,71]) and lanthanum carbonate versus CBPBs (N = 2 [59, 60])
For UMICs, incremental net benefit (INB) of sevelamer versus CBPBs were pooled across two studies [47, 48] with values of $34,168.9 (− 638.0 to 68,975.7), suggesting sevelamer was more costeffective than CBPBs, this was not significant, see Fig. 2b
Summary
Chronic kidney disease (CKD) represents a significant global public health burden with high economic costs related to morbidity and mortality [1]. Evidence related to newer NCBPBs (e.g., ferric citrate, sucroferric oxyhydroxide, etc.) has not been previously reviewed This SR and MA assessed the cost-effectiveness of PBs available under current practice guidelines for the treatment of hyperphosphatemia in CKD patients. EE studies (e.g., cost-utility analysis (CUA) or cost-effectiveness analysis (CEA)) were eligible if they met the following criteria: adult CKD with hyperphosphatemia, compared any pair of PBs regardless of dosage and treatment duration (CBPBs: calcium carbonate/acetate; NCBPBs: sevelamer, lanthanum carbonate, ferric citrate, sucroferric oxyhydroxide, aluminum hydroxide, colestimide, bixalomer, nicotinic acid), and any EE outcomes including incremental cost-effectiveness ratio (ICER), incremental cost-utility ratio (ICUR), INB/net monetary benefit (NMB), incremental cost (ΔC), incremental effectiveness (ΔE, e.g., life years (LYs) gained/lost and quality-adjusted life years (QALYs)). A two-sided p value < 0.05 was considered statistically significant
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