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A Cost-Utility Comparison of Four First-Line Medications in Painful Diabetic Neuropathy

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Abstract

Background: Painful diabetic neuropathy is common and adversely affects patients’ quality of life and function. Several treatment options exist, but their relative efficacy and value are unknown.

Objective: To determine the relative efficacy, costs and cost effectiveness of the first-line treatment options for painful diabetic neuropathy.

Methods: Published and unpublished clinical trial and cross-sectional data were incorporated into a decision analytic model to estimate the net health and cost consequences of treatment for painful diabetic peripheral neuropathy over 3-month (base case), 1-month and 6-month timeframes. Efficacy was measured in QALYs, and costs were measured in $US, year 2006 values, using a US thirdparty payer perspective.

The patients included in the model were outpatients with moderate to severe pain associated with diabetic peripheral neuropathy and no contraindications to treatment with tricyclic antidepressants. Four medications were compared: desipramine 100 mg/day, gabapentin 2400 mg/day, pregabalin 300 mg/day and duloxetine 60 mg/day.

Results: Desipramine and duloxetine were both more effective and less expensive than gabapentin and pregabalin in the base-case analysis and through a wide range of sensitivity analyses. Duloxetine offered borderline value compared with desipramine in the base case ($US47 700 per QALY), but not when incorporating baseline-observation-carried-forward analyses of the clinical trial data ($US867 000 per QALY). The results were also sensitive to the probability of obtaining pain relief with duloxetine.

Conclusions: Desipramine (100 mg/day) and duloxetine (60 mg/day) appear to be more cost effective than gabapentin or pregabalin for treating painful diabetic neuropathy. The estimated value of duloxetine relative to desipramine depends on the assumptions made in the statistical analyses of clinical trial data.

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Acknowledgements

The authors thank Robert Dworkin for his thoughtful review of an early version of the manuscript.

Dr A.B. O’Connor was supported by an institutional career development award (T32 AG020493-02) from the National Institute of Aging. Dr K. Noyes was supported in part by grant K01 AG 20980 from the National Institute of Aging. Dr R.G. Holloway was supported in part by a grant K24 NS4 2098 from the National Institute of Neurological Disorders and Stroke.

This publication was also made possible in part by grant number 1 UL1 RR024160-01 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and the NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH. Information on NCRR is available at URL: http://www.ncrr.nih.gov/. Information on re-engineering the clinical research enterprise can be obtained from URL: http://nihroadmap.nih.gov/clinicalresearch/overview-translational.asp.

None of the sources of funding had any role in any aspect of this study or the decision to publish.

Dr A.B. O’Connor has received research support unrelated to diabetes or diabetic neuropathy from Endo Pharmaceuticals and The Mayday Fund. Dr K. Noyes has received research support unrelated to diabetes or diabetic neuropathy from CPI/Guidant Corporation. Dr R.G. Holloway has received research support unrelated to diabetes or diabetic neuropathy from Pfizer (grant unrelated to the study drugs, support ended in 2003).

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Authors and Affiliations

  1. Department of Medicine, University of Rochester School of Medicine and Dentistry, University of Rochester, 601 Elmwood Avenue, Box MED/HMD, Rochester, New York, 14642, USA

    Alec B. O’Connor

  2. Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA

    Katia Noyes

  3. Department of Neurology, University of Rochester School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA

    Robert G. Holloway

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Correspondence to Alec B. O’Connor.

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O’Connor, A.B., Noyes, K. & Holloway, R.G. A Cost-Utility Comparison of Four First-Line Medications in Painful Diabetic Neuropathy. Pharmacoeconomics 26, 1045–1064 (2008). https://doi.org/10.2165/0019053-200826120-00007

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