Cost-effectiveness analysis and budgetary impact of anidulafungin treatment for patients with candidemia and other forms of invasive candidiasis in Brazil

Publication summary

Previously published estimates of the national incidence of invasive candidiasis (IC), including candidemia, in Brazil place it at about 2.5 cases per 1,000 hospitalizations. International guidelines call for first-line treatment with echinocandins and second-line or rescue treatment with amphotericin B deoxycholate or amphotericin B lipid complex. Brazil’s National Health Surveillance Agency recommends the same: first-line treatment with anidulafungin and second-line therapy with amphotericin B lipid complex, amphotericin B deoxycholate, or liposomal amphotericin B when IC cases are refractory or resistant to first-line treatment or when anidulafungin is unavailable. Brazil’s Unified Health System’s strategic stock, however, includes itraconazole and amphotericin B lipid complex for treatment of IC. This study evaluated the cost-effectiveness and budget impact of treating IC with anidulafungin compared with amphotericin B deoxycholate or amphotericin B lipid complex, finding that incorporation of anidulafungin as a first-line therapy for IC could save the Brazilian health system up to R$150 million reais (about $29.2 million USD) over 5 years.

Who this is for

• Health policymakers in Brazil and Latin America
• Health economists

Key findings

Cost-effectiveness analysis

To perform the cost-effectiveness analysis, the researchers used a decision tree, in which the effectiveness endpoints were survival and treatment response rate. Costs for medication use and treatment of toxic and adverse events (e.g., acute renal failure) were obtained from databases maintained by Brazil’s Ministry of Health and also estimated using international data sources. The incremental cost-effectiveness ratio (ICER) was defined as the difference in direct medical costs and drug costs divided by the difference in the absolute response rate (i.e., treatment success and survival). 

When effectiveness was measured by successful response rate, anidulafungin had a better cost-effectiveness ratio than amphotericin B deoxycholate or amphotericin B lipid complex. Anidulafungin was more cost-effective than amphotericin B deoxycholate when the potential for acute renal failure and the need for dialysis was factored into the model.

When effectiveness was measured by survival, anidulafungin had a better cost-effectiveness ratio (R$988 or about $192 USD) compared with amphotericin B deoxycholate (R$16,359 or about $3,183 USD).

Budget impact analysis

Very little difference exists between the costs of treating IC with anidulafungin (R$11,400 or about $2,218 USD) and amphotericin B deoxycholate (R$11,299 or about $2198 USD), so a budget impact analysis evaluated the cost-effectiveness of anidulafungin over 5 years, given the potential for nephrotoxicity associated with amphotericin B formulations. 

Although additional costs related to using anidulafungin to meet expected demand for IC therapy were estimated to reach R$20 million (about $3.9 million USD) over 5 years, incorporation of anidulafungin as first-line treatment had the best cost-effectiveness ratio given the costs to treat nephrotoxicity and acute renal failure associated with amphotericin B deoxycholate. Despite the additional costs associated with anidulafungin, 5-year savings could be expected to reach R$80 million (about $15.6 million USD) to R$150 million (about $29.2 million USD) when compared to possible increases in the need for dialysis and costs associated with further treatment if amphotericin B formulations continued to be used as first-line care.

Recommendations

Brazil is in the process of hosting a public consultation on whether anidulafungin should be incorporated into candidiasis treatment. The researchers suggest that—given anidulafungin’s positive safety profile when compared with other antifungals, international recommendations that it be used for IC, and its cost-effectiveness over time—anidulafungin should be incorporated by the Brazilian health system as a first-line antifungal for IC.