Duloxetine plus usual care cost effective in moderate-pain knee OA
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Adding the antidepressant duloxetine to usual care for knee osteoarthritis with moderate pain, regardless of any depression screening or symptoms, is cost effective, according to findings published in Arthritis Care & Research.
“Duloxetine, a serotonin-norepinephrine reuptake inhibitor that is FDA-approved for major depressive disorder and knee OA, is effective in treating depression and OA pain independent of depressive symptoms,” Nora K. Lenhard, BA, of Brigham and Women’s Hospital, in Boston, and colleagues wrote. “Given the negative impact depression has on OA management, incorporating a treatment that could affect both conditions simultaneously could improve outcomes. Duloxetine may also alleviate some of the economic burden posed by medical costs associated with depression by leading to remission.”
“However, while depression screening is recommended for all adults and may be especially important in this population, some studies raise questions about the feasibility and efficacy of incorporating screening into routine care,” they added. “Additionally, rheumatologists and orthopedists may be reluctant to screen for depression due to time constraints or feeling that other providers would be better suited to depression management.”
To analyze the cost effectiveness of adding duloxetine (Cymbalta, Eli Lilly & Co.) to standard knee OA care, regardless of depression screening, Lenhard and colleagues compared three strategies using the Osteoarthritis Policy Model, a validated computer microsimulation of knee OA. The three included strategies were standard care; standard care plus duloxetine only for those who screen positive for depression on the Patient Health Questionnaire 9 (PHQ‐9); and universal duloxetine plus standard care. Key outcomes included quality‐adjusted life years (QALYs), lifetime direct medical costs and incremental cost‐effectiveness ratios (ICERs), discounted at 3% annually.
The researchers drew their model inputs published literature and national databases. These included: $721 to $937 for the annual cost of duloxetine, a WOMAC score of 17.5 as the average pain reduction for duloxetine, and a 27.4% likelihood of depression remission with duloxetine. In addition, they examined two willingness‐to‐pay (WTP) thresholds — $50,000/QALY and $100,000/QALY. Lastly, the researchers addressed uncertainty in the model inputs by varying the parameters related to the PHQ‐9, as well as duloxetine’s cost, efficacy and toxicities.
According to the researchers, adding duloxetine only for patients who screened for depression led to an additional 17 QALYs per 1,000 patients, and increased costs by $289 per patient (ICER = $17,000 per QALY). Meanwhile, universal duloxetine, regardless of screening, led to an additional 31 QALYs per 1,000 patient and increased costs by $1,205 per patient (ICER = $39,300 per QALY). Based on the majority of their sensitivity analyses, the researchers concluded that universal duloxetine was cost‐effective at the $100,000 per QALY threshold.
“Incorporating duloxetine’s dual efficacy for pain and depressive symptoms offers a better understanding of duloxetine’s potential value,” Lenhard and colleagues wrote. “Given the economic burden that depression and knee OA place on the health care system and the prevalence of inadequately treated depression in this population, identifying treatments that can address these issues together is valuable. This analysis provides evidence that, even without screening for depressive symptoms, introducing duloxetine after NSAIDs fail to provide relief in knee OA patients with moderate pain offers good value as a pain management option.”
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