Inpharma 1518 - 17 Dec 2005

Atomoxetine adds up in ADHD– Suzanne Sullivan –

With a prevalence of approximately 5%, attention-deficit hyperactivity disorder (ADHD) can have an academicand social impact leading to difficulties with relationships and employment. Atomoxetine [Strattera] has beenrecently launched in Norway and The Netherlands as a non-stimulant alternative to traditional therapies for thetreatment of ADHD. Two studies presented at the 8th Annual European Congress of the International Society forPharmacoeconomics and Outcomes Research (ISPOR) [Florence, Italy; November 2005] evaluated the costeffectiveness of atomoxetine for ADHD in these two countries, compared with traditional stimulant therapies.The studies showed that, although the costs were greater, atomoxetine was associated with gains in quality-adjusted life-years (QALYs) versus comparator therapies. Furthermore, the duration of response was prolongedwith atomoxetine therapy, compared with methylphenidate.

The incidence of ADHD in children and adolescents is associated with estimated incremental costs of NOK109approximately 5% and 5–9% in Norway and and NOK64 for each additional symptom-free dayThe Netherlands, respectively. The difficulties in compared with IR methylphenidate and XRacademic and social aspects associated with ADHD can methylphenidate, respectively.lead to problems in gaining employment and developing In the three patient populations, treatment withrelationships. Patients with ADHD may eventually be at atomoxetine was also associated with an increase in thean increased of substance abuse, crime and injury. The average duration of response, compared with IRmore severe cases require treatment, with stimulants methylphenidate, XR methylphenidate and nosuch as methylphenidate being typical first-line medication. For population 1, an estimated 71.5% oftherapies. The two studies presented at the ISPOR atomoxetine recipients were responders at month 12,meeting were designed to compare the cost whereas 49.1% of patients in the comparator arms wereeffectiveness of the non-stimulant atomoxetine with responders.stimulant medications in the treatment of children with A sensitivity analysis showed that the model resultsADHD in Norway and The Netherlands, respectively. were robust to changes in the most important variables.

The key indicators of the cost effectiveness ofValue for money in Norway atomoxetine were the utility values.The first study was conducted by researchers from theUK and Norway who used a Markov model to estimate

Table 1. Incremental cost effectiveness ofthe cost effectiveness of atomoxetine therapy comparedatomoxetine for the treatment of ADHD in Norwaywith current treatment options.1* The study included

children from Norway with ADHD who were stratified Patient Incremental Incremental Incrementalpopulation: cost (€) QALYs cost perin one of three patient populations:

gained QALY gained• population 1: stimulant-naive patients, with or(€)without manageable comorbidities, eligible for all

Population 1:medication options (first-line patients)vs IR 783 0.0307 25 463• population 2: stimulant-failure patients, without

methylphenidatecontraindicated comorbidities, ineligible forvs XR 461 0.0240 19 162methylphenidate (second-line patients)

methylphenidate• population 3: patients with unmanageablePopulation 2:contraindicated comorbidities, ineligible for

vs no medication 879 0.0409 21 497methylphenidate (first- and second-line patients).Population 3:For each population, a treatment algorithm was

vs no medication 793 0.0354 22 385constructed for first-, second- and third-line therapiescomprising atomoxetine, immediate-release (IR) orsustained-release (XR) methylphenidate, and no

Cost effective in The Netherlandsmedication.Researchers from the UK and The NetherlandsThe 14 health states incorporated into the Markov

conducted a study in children with ADHD inprocess represented a range of outcomes for eachThe Netherlands, using a similar design to that of thetreatment option. A survey of 83 parents of children withfirst study.2** The three patient populations wereADHD was used for the utility values. The modelidentical to those in the first study, except forcalculated costs and outcomes over a 1 year period,population 3 who were ineligible for any stimulantusing the perspective of the Norwegian healthcaremedication. The treatment algorithms developedsystem for the calculation of direct costs of treatment.consisted of five treatment options: atomoxetine, IR orAlthough atomoxetine was associated with additionalXR methylphenidate, dexamfetamine, tricycliccosts compared with IR methylphenidate, XRantidepressants and no medication.methylphenidate and no medication, additional QALYs

Incremental costs per QALY gained with atomoxetinewere gained [see table 1]. The incremental QALYs gainedcompared with the other therapies were estimated within the three patient populations ranged froma Markov model using Monte Carlo simulation.0.0240–0.0409; incremental costs per QALY gainedOutcomes and costs were calculated over 12 months,associated with atomoxetine ranged from €19 162 tousing the Dutch societal perspective to estimate direct€25 463. This analysis suggests that atomoxetine "offersand indirect costs.good value-for-money in the treatment of children with

In population 1, treatment with atomoxetine wasADHD in Norway," said the researchers.associated with higher costs and more QALYs gained,According to a secondary analysis, atomoxetine was

1

Inpharma 17 Dec 2005 No. 15181173-8324/10/1518-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved

Single Article

Atomoxetine adds up in ADHD – continuedcompared with IR methylphenidate and XR In the sensitivity analysis, the model was shown to bemethylphenidate [see table 2]. Similarly, atomoxetine robust to changes in the most important variables; utilitywas associated with greater costs and QALYs gained in values were key indictors of cost effectiveness.population 2, compared with dexamfetamine. Cost- The response profile for atomoxetine versuseffectiveness ratios showed that atomoxetine would be comparator therapies was similar to that found in theconsidered good value for money in both populations. first study. Atomoxetine increased the mean duration ofHowever, in population 3, atomoxetine was compared response, compared with IR methylphenidate and XRwith tricyclic antidepressants and was associated with methylphenidate in population 1. An estimated 81.6%lower costs and better outcomes, and was thus cost and 78 of patients in the atomoxetine and comparatorsaving. groups, respectively, were responders at 12 months.

A secondary analysis estimated that atomoxetine was* The study was supported by Eli Lilly Norway, with which one of theassociated with incremental costs of €118 and €107 investigators was affiliated.

per extra symptom-free day, compared with IR ** The study received financial support from Eli Lilly, The Netherlands,methylphenidate and XR methylphenidate, respectively. with which one of the investigators was affiliated.

1. Tilden D, et al. A modelled economic evaluation of atomoxetine (strattera) forthe treatment of three patient groups with attention deficit hyperactivity disorder.Table 2. Cost effectiveness of atomoxetine for theValue in Health 8: A197 (plus poster) abstr. PMH5, No. 6, Dec 2005.treatment of ADHD in The Netherlands

2. Laing A, et al. A modelled economic evaluation comparing atomoxetine withcurrent therapies for the treatment of children with attention deficit/hyperactivityPatient population Incremental Incremental Incrementaldisorder in The Netherlands. Value in Health 8: A198 (plus poster) abstr.cost (€) QALYs cost perPMH10, No. 6, Dec 2005.gained QALY

800999754gained (€)

Population 1:vs IR +495 0.0263 18 831

methylphenidatevs XR +448 0.0197 22 804

methylphenidatePopulation 2:

vs dexamfetamine +369 0.0281 13 120Population 3:

vs tricyclic –151 0.0316 dominateda

antidepressantsa atomoxetine cost less and was more effective than tricyclicantidepressants

2

1173-8324/10/1518-0002/$14.95 Adis © 2010 Springer International Publishing AG. All rights reservedInpharma 17 Dec 2005 No. 1518