Drugs & Aging

, Volume 26, Issue 9, pp 791–801 | Cite as

Cost Effectiveness of Rasagiline and Pramipexole as Treatment Strategies in Early Parkinson’s Disease in the UK Setting

An Economic Markov Model Evaluation
  • Alan Haycox
  • Christophe Armand
  • Susana Murteira
  • John Cochran
  • Clément François
Original Research Article



Levodopa is the most effective treatment for the symptoms of Parkinson’s disease (PD). However, after an initial period of benefit, several limitations become apparent, including motor complications such as dyskinesia. Dyskinesia can severely affect patients’ quality of life and increases healthcare resource use. Thus, delaying the need for levodopa, and therefore the onset of levodopa-induced dyskinesia, is important.


The aim of this study was to compare the cost effectiveness, from a UK healthcare payer perspective, of two antiparkinsonian treatment strategies in early PD: first-line monotherapy with rasagiline, a novel monoamine oxidase B inhibitor; and the non-ergoline dopamine receptor agonist pramipexole.


An economic Markov model was developed as a pragmatic tool to derive comparative information on the effectiveness, utility and costs of these two strategies over a 5-year period. Model input data were obtained from the TEMPO study for rasagiline and from a study by the Parkinson Study Group for pramipexole. Effectiveness outcomes were time to levodopa and time to levodopa-induced dyskinesia. Cost and quality-adjusted life-year (QALY) data were derived from published sources.


Rasagiline was the dominant strategy. Compared with pramipexole, use of the rasagiline strategy was estimated to reduce costs by 18% per patient over 5 years and was associated with an additional 10% delay in dyskinesia onset (0.41 years; 95% CI 0.27, 0.55). This strategy was also found to prolong the time to levodopa initiation by 25% through a gain of 0.83 levodopa-free years (95% CI 0.56, 1.1). In addition, use of the rasagiline strategy was found to generate a 5% gain in QALYs over 5 years compared with the pramipexole strategy (3.7±0.02 vs 3.51±0.03). Sensitivity analyses confirmed that the model was robust.


Rasagiline represents a cost-effective alternative to pramipexole in the treatment of early PD in the UK.



Funding from H. Lundbeck A/S supported this work.

Professor Alan Haycox has no conflicts of interest that are directly relevant to the content of this study. Christophe Armand, Susana Murteira, John Cochran and Clément François are employees of H. Lundbeck A/S, the marketing authorization holder for rasagiline in several European countries.

The authors wish to express their sincere thanks to and acknowledge Dr Donald Grosset, of the Department of Neurology, Southern General Hospital, Glasgow, for his extensive neurological and scientific advice on the content of this article. The authors would also like to thank Natalie Barker from Wolters Kluwer Health for her assistance with editing of the manuscript.


  1. 1.
    Jankovic J. Motor fluctuations and dyskinesias in Parkinson’s disease: clinical manifestations. Mov Disord 2005; 20Suppl. 11: S11–6PubMedCrossRefGoogle Scholar
  2. 2.
    Marsden CD, Parkes JD. “On-off” effects in patients with Parkinson’s disease on chronic levodopa therapy. Lancet 1976 Feb 7; 1(7954): 292–6PubMedCrossRefGoogle Scholar
  3. 3.
    Nutt JG, Holford NH. The response to levodopa in Parkinson’s disease: imposing pharmacological law and order. Ann Neurol 1996 May; 39(5): 561–73PubMedCrossRefGoogle Scholar
  4. 4.
    Obeso JA, Rodriguez-Oroz MC, Chana P, et al. The evolution and origin of motor complications in Parkinson’s disease. Neurology 2000; 55 (11 Suppl. 4): S13–20; discussion S1–3PubMedGoogle Scholar
  5. 5.
    Schrag A, Quinn N. Dyskinesias and motor fluctuations in Parkinson’s disease: a community-based study. Brain 2000 Nov; 123 Pt 11:2297–305PubMedCrossRefGoogle Scholar
  6. 6.
    Muller T, Russ H. Levodopa, motor fluctuations and dyskinesia in Parkinson’s disease. Expert Opin Pharmacother 2006 Sep; 7(13): 1715–30PubMedCrossRefGoogle Scholar
  7. 7.
    Damiano AM, McGrath MM, Willian MK, et al. Evaluation of a measurement strategy for Parkinson’s disease: assessing patient health-related quality of life. Qual Life Res 2000 Feb; 9(1): 87–100PubMedCrossRefGoogle Scholar
  8. 8.
    Findley L, Aujla M, Bain PG, et al. Direct economic impact of Parkinson’s disease: a research survey in the United Kingdom. Mov Disord 2003 Oct; 18(10): 1139–45PubMedCrossRefGoogle Scholar
  9. 9.
    Hagell P, Nordling S, Reimer J, et al. Resource use and costs in a Swedish cohort of patients with Parkinson’s disease. Mov Disord 2002 Nov; 17(6): 1213–20PubMedCrossRefGoogle Scholar
  10. 10.
    Maurel F, Lilliu H, Le Pen C. Social and economic cost of L-dopa-induced dyskinesias in patients with Parkinson’s disease. Rev Neurol (Paris) 2001 May; 157(5): 507–14Google Scholar
  11. 11.
    Pechevis M, Clarke CE, Vieregge P, et al. Effects of dyskinesias in Parkinson’s disease on quality of life and health-related costs: a prospective European study. Eur J Neurol 2005 Dec; 12(12): 956–63PubMedCrossRefGoogle Scholar
  12. 12.
    Miyasaki JM, Martin W, Suchowersky O, et al. Practice parameter: initiation of treatment for Parkinson’s disease: an evidence-based review: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2002 Jan 8; 58(1): 11–7PubMedCrossRefGoogle Scholar
  13. 13.
    LePen C, Wait S, Moutard-Martin F, et al. Cost of illness and disease severity in a cohort of French patients with Parkinson’s disease. Pharmacoeconomics 1999 Jul; 16(1): 59–69PubMedCrossRefGoogle Scholar
  14. 14.
    National Collaborating Centre for Chronic Conditions. Parkinson’s disease: national clinical guideline for diagnosis and management in primary and secondary care. London: Royal College of Physicians, 2006Google Scholar
  15. 15.
    Haute Autorité de Santé. Guide. Affection de longue durée (ALD No. 16). Syndromes parkinsoniens dégénératifs ou secondaires non réversibles [online]. Available from URL: http://www.has-sante.fr [Accessed 2007 Nov 5]
  16. 16.
    Horstink M, Tolosa E, Bonuccelli U, et al. Review of the therapeutic management of Parkinson’s disease. Report of a joint task force of the European Federation of Neurological Societies and the Movement Disorder Society — European Section. Part I: early (uncomplicated) Parkinson’s disease. Eur J Neurol 2006 Nov; 13(11): 1170–85PubMedCrossRefGoogle Scholar
  17. 17.
    IMS Health. IMS retail drug monitor [online]. Available from URL: http://www.imshealth.com [Accessed 2006 May 1]
  18. 18.
    Youdim MB, Gross A, Finberg JP. Rasagiline [N-pro-pargyl-1R(+)-aminoindan], a selective and potent inhibitor of mitochondrial monoamine oxidase B. Br J Pharmacol 2001 Jan; 132(2): 500–6PubMedCrossRefGoogle Scholar
  19. 19.
    Abassi ZA, Binah O, Youdim MB. Cardiovascular activity of rasagiline, a selective and potent inhibitor of mitochondrial monoamine oxidase B: comparison with selegiline. Br J Pharmacol 2004 Oct; 143(3): 371–8PubMedCrossRefGoogle Scholar
  20. 20.
    Hauser RA, Zesiewicz TA. Advances in the pharmacologic management of early Parkinson disease. Neurologist 2007 May; 13(3): 126–32PubMedCrossRefGoogle Scholar
  21. 21.
    Montastruc JL, Chaumerliac C, Desboeuf K, et al. Adverse drug reactions to selegiline: a review of the French pharmacovigilance database. Clin Neuropharmacol 2000 Sep–Oct; 23(5): 271–5PubMedCrossRefGoogle Scholar
  22. 22.
    Olanow CW, Rascol O. Early rasagiline treatment slows UPDRS decline in the ADAGIO delayed-start study [abstract no. WIP-11]. 133rd Annual Meeting of the American Neurological Association; 2008 Sep 21–24; Salt Lake City (UT)Google Scholar
  23. 23.
    Iskedjian M, Einarson TR. Cost analysis of ropinirole versus levodopa in the treatment of Parkinson’s disease. Pharmacoeconomics 2003; 21(2): 115–27PubMedCrossRefGoogle Scholar
  24. 24.
    Noyes K, Dick AW, Holloway RG. Pramipexole and levodopa in early Parkinson’s disease: dynamic changes in cost effectiveness. Pharmacoeconomics 2005; 23(12): 1257–70PubMedCrossRefGoogle Scholar
  25. 25.
    Hudry J, Rinne JO, Keranen T, et al. Cost-utility model of rasagiline in the treatment of advanced Parkinson’s disease in Finland. Ann Pharmacother 2006 Apr; 40(4): 651–7PubMedCrossRefGoogle Scholar
  26. 26.
    Parkinson Study Group. A randomized controlled trial comparing pramipexole with levodopa in early Parkinson’s disease: design and methods of the CALM-PD Study. Clin Neuropharmacol 2000 Jan–Feb; 23(1): 34–44CrossRefGoogle Scholar
  27. 27.
    Hoerger TJ, Bala MV, Rowland C, et al. Cost effectiveness of pramipexole in Parkinson’s disease in the US. Pharmacoeconomics 1998 Nov; 14(5): 541–57PubMedCrossRefGoogle Scholar
  28. 28.
    Sonnenberg FA, Beck JR. Markov models in medical decision making: a practical guide. Med Decis Making 1993 Oct–Dec; 13(4): 322–38PubMedCrossRefGoogle Scholar
  29. 29.
    Bonuccelli U. Comparing dopamine agonists in Parkinson’s disease. Curr Opin Neurol 2003; 16Suppl. 1: S13–9PubMedCrossRefGoogle Scholar
  30. 30.
    Etminan M, Gill S, Samii A. Comparison of the risk of adverse events with pramipexole and ropinirole in patients with Parkinson’s disease: a meta-analysis. Drug Saf 2003; 26(6): 439–44PubMedCrossRefGoogle Scholar
  31. 31.
    Parkinson Study Group. A controlled trial of rasagiline in early Parkinson disease: the TEMPO Study. Arch Neurol 2002 Dec; 59(12): 1937–43CrossRefGoogle Scholar
  32. 32.
    Parkinson Study Group. A controlled, randomized, delayed-start study of rasagiline in early Parkinson disease. Arch Neurol 2004 Apr; 61(4): 561–6CrossRefGoogle Scholar
  33. 33.
    Lew MF, Hauser RA, TEMPO Extension Group. Long-term efficacy of rasagiline in Parkinson’s disease [poster P250]. 9th International Congress of Parkinson’s Disease and Movement Disorders; 2005 Mar 5–8; New Orleans (LA)Google Scholar
  34. 34.
    Parkinson Study Group. Pramipexole vs levodopa as initial treatment for Parkinson disease: a randomized controlled trial. JAMA 2000 Oct 18; 284(15): 1931–8CrossRefGoogle Scholar
  35. 35.
    Holloway RG, Shoulson I, Fahn S, et al. Pramipexole vs levodopa as initial treatment for Parkinson disease: a 4-year randomized controlled trial. Arch Neurol 2004 Jul; 61(7): 1044–53PubMedCrossRefGoogle Scholar
  36. 36.
    Rascol O, Brooks DJ, Korczyn AD, et al. A five-year study of the incidence of dyskinesia in patients with early Parkinson’s disease who were treated with ropinirole or levodopa. 056 Study Group. N Engl J Med 2000 May 18; 342(20): 1484–91PubMedCrossRefGoogle Scholar
  37. 37.
    Parashos SA, Maraganore DM, O’Brien PC, et al. Medical services utilization and prognosis in Parkinson disease: a population-based study. Mayo Clin Proc 2002 Sep; 77(9): 918–25PubMedGoogle Scholar
  38. 38.
    Morgante L, Salemi G, Meneghini F, et al. Parkinson disease survival: a population-based study. Arch Neurol 2000 Apr; 57(4): 507–12PubMedCrossRefGoogle Scholar
  39. 39.
    Chen H, Zhang SM, Schwarzschild MA, et al. Survival of Parkinson’s disease patients in a large prospective cohort of male health professionals. Mov Disord 2006 Jul; 21(7): 1002–7PubMedCrossRefGoogle Scholar
  40. 40.
    Boehringer Ingelheim GmbH. Mirapexin®: summary of product characteristics [online]. Available from URL: http://www.sifrol.com [Accessed 2007 Jan 1]
  41. 41.
    Teva Biosciences. Azilect®. Summary of product characteristics [online]. Available from URL: http://www.azilect.eu [Accessed 2005 Jan 1]
  42. 42.
    Organisation for Economic and Co-operation and Development. OECD StatsExtracts [online]. Available from URL: http://stats.oecd.org/wbos/default.aspx?querytype=view&queryname=221 [Accessed 2008 Jan 1]
  43. 43.
    Palmer CS, Schmier JK, Snyder E, et al. Patient preferences and utilities for ‘off-time’ outcomes in the treatment of Parkinson’s disease. Qual Life Res 2000; 9(7): 819–27PubMedCrossRefGoogle Scholar
  44. 44.
    Fenelon G. Parkinson disease. Etiology, physiopathology, diagnosis, development, treatment. Rev Prat 1996 Nov 1; 46(17): 2137–44PubMedGoogle Scholar
  45. 45.
    King DB. Parkinson’s disease: levodopa complications. Can J Neurol Sci 1999 Aug; 26Suppl. 2: S13–20PubMedGoogle Scholar
  46. 46.
    Marsden CD. Parkinson’s disease. Lancet 1990 Apr 21; 335(8695): 948–52PubMedCrossRefGoogle Scholar
  47. 47.
    National Institute for Health and Clinical Excellence. Guidance for manufacturers and sponsors [online]. Available from URL: http://www.nice.org.uk/niceMedia/pdf/technicalguidanceformanufacturersandsponsors.pdf [Accessed 2001 Jan 1]
  48. 48.
    Biglan KM, Schwid S, Eberly S, et al. Rasagiline improves quality of life in patients with early Parkinson’s disease. Mov Disord 2006 May; 21(5): 616–23PubMedCrossRefGoogle Scholar
  49. 49.
    Martinez-Martin P, Deuschl G. Effect of medical and surgical interventions on health-related quality of life in Parkinson’s disease. Mov Disord 2007 Apr 30; 22(6): 757–65PubMedCrossRefGoogle Scholar
  50. 50.
    Constantinescu R, Romer M, McDermott MP, et al. Impact of pramipexole on the onset of levodopa-related dyskinesias. Mov Disord 2007 Jul 15; 22(9): 1317–9PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2009

Authors and Affiliations

  • Alan Haycox
    • 1
  • Christophe Armand
    • 2
  • Susana Murteira
    • 2
  • John Cochran
    • 2
  • Clément François
    • 2
  1. 1.University of Liverpool Management SchoolLiverpoolUK
  2. 2.H. Lundbeck A/SParisFrance

Personalised recommendations