This article is a study on the cost-effectiveness of Ibandronate vs. Alendronate used in the treatment of osteoporosis, in a specialized clinic in Tirana.
Study on the Cost-effectiveness of Ibandronate vs. Alendronate Used in the Treatment of Osteoporosis
Abstract: Osteoporosis is “a systemic skeletal disease with a high prevalence. Biphosphonates are medicaments that are chosen for their efficacy in reducing fracture incidence, increasing bone density, and improving bone microarchitecture. The aim of the study is to evaluate the effectiveness of the drugs (ibandronate and alendronate) used in osteoporosis treatment, in post-menopausal women over the age of 50 years at a specialized clinic in Tirana; to calculate the annual cost of treatment of osteoporosis and to perform cost-effectiveness analyze.
Methods: Retrospective. The patients were all female, in menopause or post-menopause, with T-scores -1 to -6, and treated with alendronate or ibandronate. The effectiveness is calculated as the average percentage of change in bone mineral density (av. % of change in BMD) for the year 2011 vs. 2010 baseline. The annual cost of the treatment of osteoporosis according to the protocols and the cost of the examination with DXA scan (dual x-ray absorptiometry) were calculated. Finally, a comparison of the cost-effectiveness was performed.
Conclusion: Patients with osteoporosis treated with Ibandronate, at our clinic in Tirana, have an average change from baseline higher compared with patients treated with Alendronate, with a statistically significant difference between them (Man Whitney U = 66.0, p < 0.01).
The annual cost of the disease, when treated with ibandronate, is 1.3 times higher than the annual cost of treatment with alendronate. Ibandronate is more cost-effective than all other alendronate.
Introduction: Osteoporosis is “a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fractures” (1)
The World Health Organization defines osteoporosis as “bone density 2.5 standard deviations (SDs) below the mean for young white adult women at the lumbar spine, femoral neck or forearm”. (2)
Osteoporosis leads to nearly 9 million fractures each year worldwide and over 300,000patients with fragility fractures are registered in UK hospitals each year (British Orthopaedic Association, 2007).(3)
Osteoporoza, është një sëmundje me një prevalencë të lartë edhe në Shqipëri (7.28% e popullatës dhe 9.6% tek femrat)4, e njëjtë me atë të hasur për astmën apo sëmundjet e zemrës; ……………..
Direct medical costs due to fragility fractures in the UK healthcare economy were estimated at £1.8billion in 2000, with the potential to increase to £2.2billion by 2025, and the major part of these costs were related to hip fracture care. (5)
The annual cost of osteoporosis and fractures in the US elderly was estimated at $16 billion(6)
Osteoporosis is diagnosed by a T-score, which is the number of standard deviations (SD) that the patient’s bone mineral density (BMD), measured using dual X-ray absorptiometry, differs from the mean BMD of 30-years old premenopausal women. Patients with T-scores of between -1 and -2.5 SD are said to have osteoporosis.7,8
Biphosphonates are medicaments that are chosen for their efficacy in reducing fracture incidence, increasing bone density, and improving bone microarchitecture.9-15
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Methods: Retrospective. The patients were all female, in menopause or post-menopause, 50 years old or elder, with T-scores -1 to -6, diagnosed for the 1rst time in 2010 (the 1rst BMD measurement), who have received treatment (alendronate or ibandronate) for 12 months and in 2011 have performed a 2nd BMD measurement.
The effectiveness is calculated as the average percentage of change in bone mineral density (av.% of change in BMD) of the year 2011 vs. 2010 baseline. It was calculated the annual cost of the treatment of osteoporosis according to the protocols: once monthly 150 mg oral ibandronate plus supplements (calcium, vitamin D) and once weekly 70 mg alendronate (4 times per month) plus supplements (calcium, vitamin D). There are also included other direct costs such as the examination with DXA scan (dual x-ray absorptiometry) to determine the diagnosis and the medical visits. Finally, a comparison of the cost-effectiveness will be performed.
Statistical Analysis
Data was analyzed with SPSS 20 statistical package. It used the non-parametric Man Whitney U test to compare the continuous variables, Fisher Exact test was used to compare proportions between variables, and the Odds Ratio OR for assessing the association between variables. Point estimations are accompanied by interval estimation by 95 % CI. For continuous variables is presented the average, the standard deviation, and the minimum and maximum values are. The level of statistical significance is defined at α ≤ 005. Statistical tests are two-sided.duhet te shihet gjuha e perdorur, a qendron ne anglisht?
Results of the study
Our study included 70 patients who fulfilled the inclusion criteria. 24 patients were treated with once monthly 150 mg oral ibandronate and 46 patients with once-weekly 70 mg alendronate. There were no cases of fracture among our patients.
Table 1 compares the frequency of pathologies (osteopenia and osteoporosis) in two groups of patients treated with alendronat or ibandronat.
| Osteoporosis | Osteopenia | |
| Ibandronate | 14 | 10 |
| Alendronate | 18 | 28 |
OR= 1.3 95%CI 0.5 – 4.2 p=0.4
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The number of patients treated with alendronate is 1.3 times higher than the number of patients treated with ibandronate in the case of osteoporosis. (OR = 1.3, 95% CI 0.5-4.2, p = 0.4).
Chart 1
Calculation of efficiency
We have to calculate the average percentage of change of BMD (2011) to baseline (2010):
Table2. In the group of Alandronate (N=46) we have found this data:
| Osteoporosis n=18 | Osteopeni n= 28 | |||
| M (SD)
min – max |
M (SD)
min – max |
Mann-Whitney U | p | |
| T Score 2010 | -3.2 (0.7)
-4.6 – -2.5 |
-1.9 (0.4)
-2.4 – -1.1 |
507.0 | <0.001 |
| T Score 2011 | -3.1 (0.8)
-4.7 – -2.2 |
-1.8 (0.6)
-2.4 – -1.1 |
515.5 | <0.001 |
| Age, yrs | 61.2 (8.0)
51.0 – 79.0 |
59.1 (7.8)
51.0 – 81.0 |
223.5 | 0.3 |
| Height, m | 1.5 (0.05)
1.4 – 1.6 |
1.5 (0.07)
1.4 – 1.7 |
304.5 | 0.3 |
| Weight, kg | 58.8 (8.3)
46.0 – 73.0 |
68.6 (11.1)
51.0 – 95.0 |
376.5 | 0.01 |
| *Age-Group, yrs | n (%) | n (%) | OR
(95% CI) |
|
| 50 -59 yrs | 8 (17) | 19 (41) | – | |
| 60 -69 yrs | 7 (15.2) | 6 (13.0) | 1.6
0.4 – 6.7 |
0.4 |
| >70 yrs | 3 (7) | 3 (7) | 2.8
0.4 – 25.2 |
0.3 |
*Fisher exact test p=0.3
There are 46 patients treated with alendronate. 18 ( 39.1 %) (95% ; CI 29.7 – 52.1) of them suffer from osteoporosis and 28 ( 60.9 % ) (95 % CI 47.8 – 74.2) from osteopenia, with no statistically significant difference between them, p = 0.9
Grupmosha 60 – 69 vjeç ka 1.6 herë më tepër gjasa që të vuajnë nga Osteoporoza sesa grupmosha 50-59 vjeç, por pa ndryshim sinjifikant ndërmjet tyre (OR=1.6; 95%CI 0.4–6.7; p=0.4)
Grupmosha >70 vjeç ka 2.8 herë më tepër gjasa që të vuajnë nga osteoporoza sesa grupmosha 50-59 vjeç, por pa ndryshim sinjifikant ndërmjet tyre (OR=2.8; 95%CI 0.4–25.2; p=0.3)
Pacientet me Osteopeni kanë peshë mesatare më të lartë krahasuar me pacientët me Osteoporozë, me ndryshim statistikisht të rëndësishëm ndërmjet tyre (Man Whitney U=376.5, p=0.01)
Pacientët me Osteoporozë kanë të njëjtën gjatësi mesatare me pacientët me Osteopeni, pa ndryshim statistikisht të rëndesishëm ndërmjet tyre (Man Whitney U=304.5, p=0.3).
The change from baseline for Alendronate group
The change from baseline is calculated:
Table 3
| Osteoporosis n=18 | Osteopenia n= 28 | |||
| M (SD)
min – max |
M (SD)
min – max |
Mann-Whitney U | p | |
| The change from
baseline |
2.1 (4.5)
-7.6 – 13.9 |
1.7 (6.2)
-23 – 11.1 |
316.0 | 0.2 |
Patients with osteopenia have an average change from baseline higher compared with patients with osteoporosis, no statistically significant difference between them (Man Whitney U = 316.0, p = 0.2).
Table 4. In the group of Ibandronate (N = 24) we have found this data:
| Osteoporosis n=14 | Osteopeni n= 10 | ||||
| M (SD)
min – max |
M (SD)
min – max |
Mann-Whitney U | p | ||
| T Score 2010 | -3.7 (0.7)
-5.0 – -2.7 |
-1.8 (0.3)
-2.2 – -1.4 |
140.0 | <0.001 | |
| T Score 2011 | -3.2 (0.8)
-4.4 – -1.7 |
-1.5 (0.4)
-2.1 – -1.0 |
134.5 | <0.001 | |
| Age yrs | 64.3 (7.3)
53.0 – 77.0 |
59.1 (5.0)
53.0 – 68.0 |
39.5 | 0.07 | |
| Height (m) | 1.5 (0.05)
1.4 – 1.6 |
1.5 (0.06)
1.4 – 1.6 |
71.0 | 0.9 | |
| Weight | 66.2 (10.9)
47.0 – 84.0 |
70.7 (7.1)
65.0 – 82.0 |
90.5 | 0.2 | |
| *Age-group, yrs | n (%) | n (%) | OR
(95% CI) |
||
| 50 -59 yrs | 3 (12.5) | 6 (25.0) | – | ||
| 60 -69 yrs | 8 (33.3) | 4 (16.7) | 3.7
0.6 – 27.8 |
0.2 | |
| >70 yrs | 3 (12.5) | 0 | 13
0.5 – 33.0 |
0.03 | |
*Fisher exact test p<0.05
There are 24 patients treated with Ibandronate. 14 (58.3%), (95% CI 33.2-76.5) of them suffer from osteoporosis and 10 (43.7%), (95% CI 23.4-61.7) of osteopenia, no statistically significant difference between them, p = 0.9.
Pacientët me Osteoporozë kanë një moshë mesatare më të lartë krahasuar me pacientët me Osteopeni, por pa ndryshim statistikisht të rëndësishëm ndërmjet tyre (Man Whitney U=39.5, p=0.07). Pacientët me Osteoporozë kanë të njejtën gjatësi mesatare me pacientet me Osteopeni, pa ndryshim statistikisht të rëndësishëm ndermjet tyre (Man Whitney U=71.0, p=0.9)
Grupmosha 60 – 69 vjeç ka 3.7 herë më tepër gjasa që të vuajë nga Osteoporoza sesa grupmosha 50-59 vjeç, por pa ndryshim sinjifikant ndërmjet tyre (OR=3.7; 95%CI 0.6–27.8; p=0.2).
Grupmosha >70 vjeç ka 13 herë më tepër gjasa që të vuajë nga osteoporoza sesa grupmosha 50-59 vjeç me ndryshim sinjifikant ndërmjet tyre (OR=13; 95%CI 0.5–33.0; p=0.03).
Pacientët me Osteopeni kanë peshë mesatare më të lartë krahasuar me pacientët me Osteoporozë, por pa ndryshim statistikisht të rëndësishëm ndërmjet tyre (Man Whitney U=90.5, p=0.2)
The change from baseline for Ibandronate group (N=24)
The change from baseline is calculated:
Table5
| Osteoporosis n=14 | Osteopenia n= 10 | |||
| M (SD)
min – max |
M (SD)
min – max |
Mann-Whitney U | p | |
| The change from
baseline |
7.3 (6.1)
-0.5 – 17.3 |
3.3 (2.2)
-1.3 – 6.3 |
43.0 | 0.1 |
Patients with osteoporosis have an average change from baseline higher compared with patients with osteopenia, with no statistically significant difference between them (Man Whitney U = 43.0, p = 0.1)
Comparison of change from baseline for patients with osteoporosis referring to the two drugs.
Table 6.
| Alendronate
n=18 |
Ibandronate
n= 14 |
|||
| M (SD)
min – max |
M (SD)
min – max |
Mann-Whitney U | p | |
| The change from
baseline |
2.1 (4.5)
-7.6 – 13.9 |
7.3 (6.1)
-0.5 – 17.3 |
66.0 | <0.01 |
Chart 2. The change from baseline for patients with osteoporosis
Pacientët me Osteoporozë të mjekuar me medikamentin Ibandronat kanë një ndryshim mesatar nga baseline më të lartë krahasuar me pacientet e mjekuar me Alendronat, me ndryshim statistikisht të rëndesishëm ndërmjet tyre (Man Whitney U=66.0, p<0.01).
Table 7. Percentages of the average change of BMD from baseline
| Total | Osteoporosis | Ostopenia | |
| Alendronate | 1.83564848 | 2.081694 | 1.677476 |
| Ibandronate | 5.635355 | 7.27025 | 3.346503 |
Chart 3.
Nga figura rezulton se efikasiteti i medikamentit ibandronat (5.6) është dukshëm më i lartë se efikasiteti i medikamentit alendronat (1.8). Efikasiteti i medikamentit ibandronat tek pacientët me osteoporozë (7.3) është dukshëm më i lartë se efikasiteti i medikamentit alendronat (2.1). Efikasiteti i medikamentit ibandronat tek pacientët me osteoponi (3.3) është më i lartë se efikasiteti i medikamentit alendronat (1.7).
Cost analysis
We consider only direct costs such as DXA scanner examinations, medical visits, and medications costs (drugs and supplements), according to a well-defined treatment protocol. In Albania, there is only one kind of ibandronate (only one brand) 150 mg / once a month, while there are lots of alendronate (different brands) 70 mg / 4 times per month, which we have called A1, A2, A3, A4, A5. We have calculated the costs of only ibandronate and the costs of five types of alendronate, including the alendronate produced by a pharmaceuticals firm in the country, which has the lowest price in the market. In both cases, the basic treatment is associated with calcium and vitamin D.
Table 8 Annual Cost of treatment and cost of examination
| Nr | Currency | Quantity | Cost | Month | Annual Costs | |
| 1 | Diagnostics | |||||
| skaner DXA | Lek1 | 1 | 4,000 | 4,000 | ||
| Medical examination | 1 | 1,000 | 1,000 | |||
| 2 | Type of Alendronat 70mg | |||||
| A1 | lek | 4 | 3,410 | 12 | 40,920 | |
| A2 | lek | 4 | 2,093 | 12 | 25,116 | |
| A3 | lek | 4 | 3,301 | 12 | 39,612 | |
| A4 | lek | 4 | 4,102 | 12 | 49,224 | |
| A.5 (Albanian Product) | lek | 4 | 1,200 | 12 | 14,400 | |
| 3 | Ibandronat 150 mg | |||||
| lek | 1 | 4,873 | 12 | 58,476 | ||
| 4 | Calcium Carbonat 1000 mg + Colecalciferol 880 UI | lek | 30 | 1,019 | 12 | 12,228 |
Table 9 Cost of illness according to the type of medication
| Type of Alendronat | 1+2+4 | Annual costs |
| A1 | lek | 58,148 |
| A2 | lek | 42,344 |
| A3 | lek | 56,840 |
| A4 | lek | 66,452 |
| A5 | lek | 31,628 |
| Type of Ibandronat | 1+3+4 | Annual costs |
| I1 | lek | 75,704 |
The annual cost of the disease, when treated with ibandronate, is 2.4 times higher than the annual cost of treatment with alendronate the alendronate is produced by a pharmaceuticals firm in the country, which has the lowest price in the market, respectively 537[1] euro versus 226 euro per patient in alendronate group.
Having all the annual costs and the efficiency for each drug, we can compare:
Table 10
| Name | (Changes by baseline in %) |
| Efficiency of alendronate | 1.83565 |
| Efficiency of ibandronate | 5.63536 |
Table11
| Type of treatment | C/E |
| Alendronate | |
| A1 | 31,677 |
| A2 | 23,068 |
| A3 | 30,965 |
| A4 | 36,201 |
| A5 | 17,230 |
| Ibandronate | 13,434 |
The analysis of cost per efficiency unit (Table 10) shows that in the case of ibandronate the value obtained is 13.434 units and in alendronate “A1” case is 31.677 units.
Discussion of results
Patients with osteoporosis treated with Ibandronate, at our clinic in Tirana, have an average change from baseline higher compared with patients treated with Alendronate, with a statistically significant difference between them (Man Whitney U = 66.0, p < 0.01). We find in the literature that once-monthly Ibandronate was shown to be clinically comparable to weekly alendronate at increasing BMD after 12 months in the lumbar spine and total hip16
The annual cost of the disease, when treated with ibandronate, is 1.3 times higher than the annual cost of treatment with alendronate “A1 and 2.4 times higher than the annual cost of treatment with the alendronate produced by a pharmaceuticals firm in the country, which has the lowest price in the market.
So as claimed, the cost for effectiveness unit is lower (about 2.3 times) in the case of ibandronate compared to alendronate “A1”. Well, ibandronate results are the most cost-effective. Ibandronate turns more cost-effective than all other alendronates including the alendronate produced by a pharmaceuticals firm in the country, which has the lowest price in the market
References
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