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Original Investigation
January 16, 2019

Cost-effectiveness of Canakinumab for Prevention of Recurrent Cardiovascular Events

Author Affiliations
  • 1Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen, Denmark
  • 2Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
  • 3Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
  • 4Department of Medicine, Stanford University, Stanford, California
  • 5Department of Management Science and Engineering, Stanford University, Stanford, California
  • 6VA Palo Alto Health Care System, Palo Alto, California
  • 7Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California
JAMA Cardiol. 2019;4(2):128-135. doi:10.1001/jamacardio.2018.4566
Key Points

Question  What is the cost-effectiveness of canakinumab for the secondary prevention of cardiovascular events?

Findings  In this cost-effectiveness analysis, the outcomes of patients with a previous myocardial infarction treated either with canakinumab therapy added to standard of care or with standard of care alone were simulated. The addition of canakinumab was estimated to increase quality-adjusted life-years (QALYs) by 0.13 and costs by $832 000, yielding an incremental cost-effectiveness ratio of $6.4 million per QALY gained.

Meaning  Canakinumab is not cost-effective at its current market price.

Abstract

Importance  In the Canakinumab Anti-inflammatory Thrombosis Outcome Study (CANTOS) trial, the anti-inflammatory monoclonal antibody canakinumab significantly reduced the risk of recurrent cardiovascular events in patients with previous myocardial infarction (MI) and high-sensitivity C-reactive protein (hs-CRP) levels of 2 mg/L or greater.

Objective  To estimate the cost-effectiveness of adding canakinumab to standard of care for the secondary prevention of major cardiovascular events over a range of potential prices.

Design, Setting, and Participants  A state-transition Markov model was constructed to estimate costs and outcomes over a lifetime horizon by projecting rates of recurrent MI, coronary revascularization, infection, and lung cancer with and without canakinumab treatment. We used a US health care sector perspective, and the base case used the current US market price of canakinumab of $73 000 per year. A hypothetical cohort of patients after MI aged 61 years with an hs-CRP level of 2 mg/L or greater was constructed.

Interventions  Canakinumab, 150 mg, administered every 3 months plus standard of care compared with standard of care alone.

Main Outcomes and Measures  Lifetime costs and quality-adjusted life-years (QALYs), discounted at 3% annually.

Results  Adding canakinumab to standard of care increased life expectancy from 11.31 to 11.36 years, QALYs from 9.37 to 9.50, and costs from $242 000 to $1 074 000, yielding an incremental cost-effectiveness ratio of $6.4 million per QALY gained. The price would have to be reduced by more than 98% (to $1150 per year or less) to meet the $100 000 per QALY willingness-to-pay threshold. These results were generally robust across alternative assumptions, eg, substantially lower health-related quality of life after recurrent cardiovascular events, lower infection rates while receiving canakinumab, and reduced all-cause mortality while receiving canakinumab. Including a potential beneficial effect of canakinumab on lung cancer incidence improved the incremental cost-effectiveness ratio to $3.5 million per QALY gained. A strategy of continuing canakinumab selectively in patients with reduction in hs-CRP levels to less than 2 mg/L would have a cost-effectiveness ratio of $819 000 per QALY gained.

Conclusions and Relevance  Canakinumab is not cost-effective at current US prices for prevention of recurrent cardiovascular events in patients with a prior MI. Substantial price reductions would be needed for canakinumab to be considered cost-effective.

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