The use of allergen immunotherapy is expected to increase as more novel delivery methods and better ways to personalize treatment are developed. A key question remains, however: Should all patients receiving the therapy be prescribed a self-injectable epinephrine autoinjector?
“Immunotherapy is a safe and effective disease-modifying treatment associated with rare therapy-associated fatality. Significant practice variation surrounds universal or contextual prescription of self-injectable epinephrine [SIE] for patients receiving AIT [allergy immunotherapy],” according to a recent study published in the Annals of Allergy, Asthma & Immunology.
Researchers from Children’s Hospital of Philadelphia and colleagues from Dartmouth-Hitchcock Medical Center in Hanover, New Hampshire, and Children’s Hospital Colorado in Aurora sought to characterize the cost-effectiveness of a universal versus contextual SIE requirement for patients receiving AIT.
The study team performed economic evaluation using cohort and microsimulation from both the societal and healthcare-sector perspectives for AIT patients. The issue was whether a universal requirement to fill SIE prescriptions at the outset of therapy should be mandated compared with requiring prescription only after a systemic reaction to immunotherapy (SRIT).
The authors determined that a universal SIE requirement for AIT is not cost-effective, with the incremental cost-effectiveness ratio for this strategy estimated at $669,327,730 per quality-adjusted life year (QALY).
In fact, costs of a universal approach exceeded those of a more context-specific strategy in which SIE was prescribed for patients only after an initial SRIT ($19,653.36, SD $4,296.66 vs. $16,232.14, SD $5,204.32). Taking into account rates of AIT discontinuation, the study team found that the universal approach was even less effective (25.555 QALY, SD 2.285) compared with a contextualized approach (25.579 QALY, SD 2.345).
“Universal SIE prescription could be cost-effective if it provided a 1000x protection against AIT fatality at a value-based cost of $24, and the annual AIT fatality rates unrealistically exceed 2.6 per 10,000 patients,” the authors write, adding, “In a simulation of potential SIE prescribing strategies for patients receiving AIT, a universal approach to an epinephrine autoinjector requirement was not cost-effective when compared to an approach in which an SIE is prescribed only to patients with prior SRIT.”
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