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PharmacoEconomics & Outcomes News 493 - 17 Dec 2005 Atomoxetine adds up in ADHD Suzanne Sullivan With a prevalence of approximately 5%, attention-deficit hyperactivity disorder (ADHD) can have an academic and social impact leading to difficulties with relationships and employment. Atomoxetine [Strattera] has been recently launched in Norway and The Netherlands as a non-stimulant alternative to traditional therapies for the treatment of ADHD. Two studies presented at the 8th Annual European Congress of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) [Florence, Italy; November 2005] evaluated the cost effectiveness of atomoxetine for ADHD in these two countries, compared with traditional stimulant therapies. The studies showed that, although the costs were greater, atomoxetine was associated with gains in quality- adjusted life-years (QALYs) versus comparator therapies. Furthermore, the duration of response was prolonged with atomoxetine therapy, compared with methylphenidate. The incidence of ADHD in children and adolescents is associated with estimated incremental costs of NOK109 approximately 5% and 5–9% in Norway and and NOK64 for each additional symptom-free day The Netherlands, respectively. The difficulties in compared with IR methylphenidate and XR academic and social aspects associated with ADHD can methylphenidate, respectively. lead to problems in gaining employment and developing In the three patient populations, treatment with relationships. Patients with ADHD may eventually be at atomoxetine was also associated with an increase in the an increased of substance abuse, crime and injury. The average duration of response, compared with IR more severe cases require treatment, with stimulants methylphenidate, XR methylphenidate and no such as methylphenidate being typical first-line medication. For population 1, an estimated 71.5% of therapies. The two studies presented at the ISPOR atomoxetine recipients were responders at month 12, meeting were designed to compare the cost whereas 49.1% of patients in the comparator arms were effectiveness of the non-stimulant atomoxetine with responders. stimulant medications in the treatment of children with A sensitivity analysis showed that the model results ADHD in Norway and The Netherlands, respectively. were robust to changes in the most important variables. The key indicators of the cost effectiveness of Value for money in Norway atomoxetine were the utility values. The first study was conducted by researchers from the UK and Norway who used a Markov model to estimate Table 1. Incremental cost effectiveness of the cost effectiveness of atomoxetine therapy compared atomoxetine for the treatment of ADHD in Norway with current treatment options. 1 * The study included children from Norway with ADHD who were stratified Patient Incremental Incremental Incremental population: cost () QALYs cost per in one of three patient populations: gained QALY gained population 1: stimulant-naive patients, with or () without manageable comorbidities, eligible for all Population 1: medication options (first-line patients) vs IR 783 0.0307 25 463 population 2: stimulant-failure patients, without methylphenidate contraindicated comorbidities, ineligible for vs XR 461 0.0240 19 162 methylphenidate (second-line patients) methylphenidate population 3: patients with unmanageable Population 2: contraindicated comorbidities, ineligible for vs no medication 879 0.0409 21 497 methylphenidate (first- and second-line patients). Population 3: For each population, a treatment algorithm was vs no medication 793 0.0354 22 385 constructed for first-, second- and third-line therapies comprising atomoxetine, immediate-release (IR) or sustained-release (XR) methylphenidate, and no Cost effective in The Netherlands medication. Researchers from the UK and The Netherlands The 14 health states incorporated into the Markov conducted a study in children with ADHD in process represented a range of outcomes for each The Netherlands, using a similar design to that of the treatment option. A survey of 83 parents of children with first study. 2 ** The three patient populations were ADHD was used for the utility values. The model identical to those in the first study, except for calculated costs and outcomes over a 1 year period, population 3 who were ineligible for any stimulant using the perspective of the Norwegian healthcare medication. The treatment algorithms developed system for the calculation of direct costs of treatment. consisted of five treatment options: atomoxetine, IR or Although atomoxetine was associated with additional XR methylphenidate, dexamfetamine, tricyclic costs compared with IR methylphenidate, XR antidepressants and no medication. methylphenidate and no medication, additional QALYs Incremental costs per QALY gained with atomoxetine were gained [see table 1]. The incremental QALYs gained compared with the other therapies were estimated with in the three patient populations ranged from a Markov model using Monte Carlo simulation. 0.0240–0.0409; incremental costs per QALY gained Outcomes and costs were calculated over 12 months, associated with atomoxetine ranged from 19 162 to using the Dutch societal perspective to estimate direct 25 463. This analysis suggests that atomoxetine "offers and indirect costs. good value-for-money in the treatment of children with In population 1, treatment with atomoxetine was ADHD in Norway," said the researchers. associated with higher costs and more QALYs gained, According to a secondary analysis, atomoxetine was 1 PharmacoEconomics & Outcomes News 17 Dec 2005 No. 493 1173-5503/10/0493-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved

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Page 1: Atomoxetine adds up in ADHD

PharmacoEconomics & Outcomes News 493 - 17 Dec 2005

Atomoxetine adds up in ADHD– Suzanne Sullivan –

With a prevalence of approximately 5%, attention-deficit hyperactivity disorder (ADHD) can have an academicand social impact leading to difficulties with relationships and employment. Atomoxetine [Strattera] has beenrecently launched in Norway and The Netherlands as a non-stimulant alternative to traditional therapies for thetreatment of ADHD. Two studies presented at the 8th Annual European Congress of the International Society forPharmacoeconomics and Outcomes Research (ISPOR) [Florence, Italy; November 2005] evaluated the costeffectiveness of atomoxetine for ADHD in these two countries, compared with traditional stimulant therapies.The studies showed that, although the costs were greater, atomoxetine was associated with gains in quality-adjusted life-years (QALYs) versus comparator therapies. Furthermore, the duration of response was prolongedwith atomoxetine therapy, compared with methylphenidate.

The incidence of ADHD in children and adolescents is associated with estimated incremental costs of NOK109approximately 5% and 5–9% in Norway and and NOK64 for each additional symptom-free dayThe Netherlands, respectively. The difficulties in compared with IR methylphenidate and XRacademic and social aspects associated with ADHD can methylphenidate, respectively.lead to problems in gaining employment and developing In the three patient populations, treatment withrelationships. Patients with ADHD may eventually be at atomoxetine was also associated with an increase in thean increased of substance abuse, crime and injury. The average duration of response, compared with IRmore severe cases require treatment, with stimulants methylphenidate, XR methylphenidate and nosuch as methylphenidate being typical first-line medication. For population 1, an estimated 71.5% oftherapies. The two studies presented at the ISPOR atomoxetine recipients were responders at month 12,meeting were designed to compare the cost whereas 49.1% of patients in the comparator arms wereeffectiveness of the non-stimulant atomoxetine with responders.stimulant medications in the treatment of children with A sensitivity analysis showed that the model resultsADHD in Norway and The Netherlands, respectively. were robust to changes in the most important variables.

The key indicators of the cost effectiveness ofValue for money in Norway atomoxetine were the utility values.The first study was conducted by researchers from theUK and Norway who used a Markov model to estimate

Table 1. Incremental cost effectiveness ofthe cost effectiveness of atomoxetine therapy comparedatomoxetine for the treatment of ADHD in Norwaywith current treatment options.1* The study included

children from Norway with ADHD who were stratified Patient Incremental Incremental Incrementalpopulation: cost (€) QALYs cost perin one of three patient populations:

gained QALY gained• population 1: stimulant-naive patients, with or(€)without manageable comorbidities, eligible for all

Population 1:medication options (first-line patients)vs IR 783 0.0307 25 463• population 2: stimulant-failure patients, without

methylphenidatecontraindicated comorbidities, ineligible forvs XR 461 0.0240 19 162methylphenidate (second-line patients)

methylphenidate• population 3: patients with unmanageablePopulation 2:contraindicated comorbidities, ineligible for

vs no medication 879 0.0409 21 497methylphenidate (first- and second-line patients).Population 3:For each population, a treatment algorithm was

vs no medication 793 0.0354 22 385constructed for first-, second- and third-line therapiescomprising atomoxetine, immediate-release (IR) orsustained-release (XR) methylphenidate, and no

Cost effective in The Netherlandsmedication.Researchers from the UK and The NetherlandsThe 14 health states incorporated into the Markov

conducted a study in children with ADHD inprocess represented a range of outcomes for eachThe Netherlands, using a similar design to that of thetreatment option. A survey of 83 parents of children withfirst study.2** The three patient populations wereADHD was used for the utility values. The modelidentical to those in the first study, except forcalculated costs and outcomes over a 1 year period,population 3 who were ineligible for any stimulantusing the perspective of the Norwegian healthcaremedication. The treatment algorithms developedsystem for the calculation of direct costs of treatment.consisted of five treatment options: atomoxetine, IR orAlthough atomoxetine was associated with additionalXR methylphenidate, dexamfetamine, tricycliccosts compared with IR methylphenidate, XRantidepressants and no medication.methylphenidate and no medication, additional QALYs

Incremental costs per QALY gained with atomoxetinewere gained [see table 1]. The incremental QALYs gainedcompared with the other therapies were estimated within the three patient populations ranged froma Markov model using Monte Carlo simulation.0.0240–0.0409; incremental costs per QALY gainedOutcomes and costs were calculated over 12 months,associated with atomoxetine ranged from €19 162 tousing the Dutch societal perspective to estimate direct€25 463. This analysis suggests that atomoxetine "offersand indirect costs.good value-for-money in the treatment of children with

In population 1, treatment with atomoxetine wasADHD in Norway," said the researchers.associated with higher costs and more QALYs gained,According to a secondary analysis, atomoxetine was

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PharmacoEconomics & Outcomes News 17 Dec 2005 No. 4931173-5503/10/0493-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved

Page 2: Atomoxetine adds up in ADHD

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Atomoxetine adds up in attention-deficit hyperactivity disorder –continued

compared with IR methylphenidate and XR A secondary analysis estimated that atomoxetine wasmethylphenidate [see table 2]. Similarly, atomoxetine associated with incremental costs of €118 and €107was associated with greater costs and QALYs gained in per extra symptom-free day, compared with IRpopulation 2, compared with dexamfetamine. Cost- methylphenidate and XR methylphenidate, respectively.effectiveness ratios showed that atomoxetine would be In the sensitivity analysis, the model was shown to beconsidered good value for money in both populations. robust to changes in the most important variables; utilityHowever, in population 3, atomoxetine was compared values were key indictors of cost effectiveness.with tricyclic antidepressants and was associated with The response profile for atomoxetine versuslower costs and better outcomes, and was thus cost comparator therapies was similar to that found in thesaving. first study. Atomoxetine increased the mean duration of

response, compared with IR methylphenidate and XRmethylphenidate in population 1. An estimated 81.6%Table 2. Cost effectiveness of atomoxetine for theand 78 of patients in the atomoxetine and comparatortreatment of ADHD in The Netherlandsgroups, respectively, were responders at 12 months.Patient population Incremental Incremental Incremental

cost (€) QALYs cost per * The study was supported by Eli Lilly Norway, with which one of thegained QALY investigators was affiliated.

gained (€) ** The study received financial support from Eli Lilly, The Netherlands,with which one of the investigators was affiliated.Population 1:

vs IR +495 0.0263 18 831 1. Tilden D, et al. A modelled economic evaluation of atomoxetine (strattera) formethylphenidate the treatment of three patient groups with attention deficit hyperactivity disorder.

Value in Health 8: A197 (plus poster) abstr. PMH5, No. 6, Dec 2005.vs XR +448 0.0197 22 8042. Laing A, et al. A modelled economic evaluation comparing atomoxetine withmethylphenidate

current therapies for the treatment of children with attention deficit/hyperactivityPopulation 2: disorder in The Netherlands. Value in Health 8: A198 (plus poster) abstr.

PMH10, No. 6, Dec 2005.vs dexamfetamine +369 0.0281 13 120800999754

Population 3:vs tricyclic –151 0.0316 dominateda

antidepressantsa atomoxetine cost less and was more effective than tricyclicantidepressants

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1173-5503/10/0493-0002/$14.95 Adis © 2010 Springer International Publishing AG. All rights reservedPharmacoEconomics & Outcomes News 17 Dec 2005 No. 493