Adding colchicine to prevent gout flares while initiating allopurinol 'very cost effective'
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Despite its increased cost in the United States, colchicine use to prevent gout flares while starting treatment with allopurinol remains “very cost effective,” according to findings published in Arthritis Care & Research.
“Allopurinol is the core therapy for gout, and starting it can be challenging because it can actually precipitate flares of gout,” Philip C. Robinson, MBChB, PhD, FRACP, of Royal Brisbane and Women’s Hospital, and the University of Queensland, in Australia, told Healio Rheumatology. “Using colchicine prophylaxis when commencing allopurinol is very important to preventing flares and making sure people continue on the allopurinol, and consequently control their gout. However, it can be very expensive in the United States, and there may be push back from insurers to fund this drug as well as allopurinol.”
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To examine the cost effectiveness of using colchicine to prevent gout flares while starting allopurinol treatment, Robinson and colleagues performed a series of analyses from the point of view of the third-party payer in both the United States and Australia. Using TreeAge Software, they developed a twoarm decision tree with one arm starting allopurinol with no colchicine prophylaxis, and the other with colchicine.
Model inputs were collected from published literature where available. The researchers then performed a univariate and probabilistic sensitivity analysis to confirm the robust nature of the modeling. The time frame used for the model was 6 months.
According to the researchers, the colchicine-prophylaxis arm demonstrated a cost of U.S. $1,276 and 0.49 quality-adjusted lifeyears, while the cost in the non-colchicine arm was U.S. $516 and 0.47 quality-adjusted lifeyears, with an incremental costeffectiveness ratio of U.S. $34,004 per quality-adjusted lifeyear gained.
In Australia, where colchicine is much less expensive, the colchicine arm cost AUS $208, compared with AUS $415 in the placebo arm. The researchers’ univariate and probability sensitivity analysis demonstrated that the results were robust to changes in input parameters.
Meanwhile, the probabilistic sensitivity analysis found that the probability of colchicine prophylaxis being the most cost-effective option was 93% in the United States and 100% in Australia.
“The key takeaways are that as well as being very clinically effective at preventing flares, [colchicine] is also very cost effective, and there should be few barriers to prescribe it,” Robinson said. “Along with other work we have done that shows that it is very safe, it should be used if at all possible when commencing allopurinol.”
Perspective
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David A. McLain, MD, FACP, FACR
Colchicine is a naturally occurring compound that has been used since 1500 BC by the pharaohs of ancient Egypt as recorded in an ancient Egyptian medical papyrus. It is considered mankind’s oldest anti-inflammatory medication. Colchicine has been used to treat and prevent acute gout attacks and to prevent attacks of familial Mediterranean fever. It is also used off-label in Behcet’s disease and to prevent pericarditis.
The drug was approved by the FDA in 1961, when many commonly used drugs at that time were ‘grandfathered’ in. However, a controversy occurred in 2009 when colchicine was approved as an NDA by the FDA under the brand name Colcrys from URL Pharma (now Takeda Pharmaceuticals) and all generics were removed from the United States market. This was prompted by the U.S. Unapproved Drug Initiative in 2006 which required older ‘grandfathered’ drugs to undergo modern testing.
As a result, colchicine (as Colcrys) increased 2000% in price, during which time, many patients suffered as they could no longer afford their medication and rheumatologists decreased use of this medication.
The present study used $4.73 for the cost of a colchicine tablet in the U.S. We would tell patients that “colchicine went from 5 cents to 5 dollars per tablet” – in contrast, the cost of colchicine in Australia is US$0.37 per tablet. This study used a prophylactic dose of colchicine of 0.6 mg PO BID, continued for 6 months. Even with the increased U.S. cost of colchicine, the data and modelling in this paper found that colchicine prevented gout flares whilst instituting allopurinol and that it was cost effective; information that can be helpful with insurers and pharmacy benefit managers.
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