Donepezil, rivastigmine, galantamine and memantine for ...

Introduction
The aim of this section is to assess the costeffectiveness
of donepezil, rivastigmine,
galantamine and memantine for AD. The
economic analysis comprises a systematic review of
the literature on the cost-effectiveness of these
drugs for AD (see Chapter 3 for details), a review
of the manufacturer submissions (cost-effectiveness)
to NICE and the presentation of cost-effectiveness
analysis (CEA) from the current review
[Southampton Health Technology Assessment
Centre (SHTAC)]. An outline discussion of the
literature on costs and health state utilities
associated with AD, and the modelling of disease
progression over time, is also given.
Cost-effectiveness: systematic
review of the literature
Results of literature search
The literature search identified 11 economic
evaluations for donepezil, 43,56,81–89 five for
rivastigmine, 90–94 five for galantamine95–99 and
three for memantine. 100–102 Two further
unpublished papers reporting on the costeffectiveness
of memantine were provided by the
manufacturer. 103,104 Also identified were three
product-specific systematic reviews105–107 and three
broader systematic reviews1,78,108 covering the costeffectiveness
of included pharmaceuticals for AD.
Review methods
A review of the cost-effectiveness literature
identified is presented. A narrative review focused
on the UK cost-effectiveness studies is provided,
presenting a separate review for each of the four
products, comprising descriptive detail, summary
tables and a UK narrative. More detailed
information is presented in the Appendices.
Where studies are only available as abstracts,
outline information is offered but further detail on
these studies is not provided. Summary
information on the identified product specific
systematic reviews, within the appropriate sections,
and a general section on systematic reviews
covering more than one product are provided. An
outline review of the industry submissions (costeffectiveness)
under each of the drug-specific
Chapter 6
Economic analysis
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Health Technology Assessment 2006; Vol. 10: No. 1
subheadings is given, with further detail on
accompanying cost-effectiveness models provided
in Appendix 15. Discussion of the associated AD
cost studies is focused on those reporting UK cost
estimates.
An outline critical appraisal of economic
evaluations using a standard checklist 39 is
presented and external validity (i.e. the
generalisability of the economic study to the UK)
using a series of relevant questions (see
Appendix 13) is considered. An assessment of the
cost-effectiveness models submitted within
industry submissions to NICE is provided, using a
framework presented by Phillips and colleagues, 109
who have synthesised the literature on the
evaluation of decision analytic models in a health
technology assessment context to present
guidelines for best practice.
Economic evaluations of donepezil
Characteristics of economic evaluations
Table 48 provides a simple summary of the study
characteristics for the nine published economic
evaluations reporting on the cost-effectiveness of
donepezil versus usual care, 43,56,81,82,84–87,89
together with summary detail on two published
abstracts. 83,88 The abstracts by Lanctôt and
colleagues 83 and Sobolewski and colleagues 88
provide limited information and are not discussed
further in this report. Further details of the study
characteristics and methods are provided in
Appendix 13. Studies represent country-specific
analyses for the UK (three studies), Sweden (two
studies), Canada (two studies), USA, Japan, Poland
and France. Table 48 reports the ‘headline’ finding
for each study; all studies except the AD2000
study43 reported drug efficacy either in terms of a
delay in disease progression, 56,81,82,84–86,88 qualityadjusted
life-year (QALY) gains83,87 or as reduced
time in need of full-time care. 89 In five studies,
donepezil treatment was described as cost
saving, 83–85,87,89 although all of these studies are
from an unclear or societal perspective, whereas in
other studies, treatment was described as cost
neutral, 82 cost incurring43,86,88 or cost saving from
a societal perspective only (i.e. with savings for
patients and caregivers, but not for the healthcare
81