Cost-Effectiveness Comparison of Salmeterol/Fluticasone Propionate versus Montelukast in the Treatment of Adults with Persistent Asthma

Objective: To compare the relative cost effectiveness of salmeterol (50mug)/ fluticasone propionate (100mug) with that of oral montelukast (10mg) as initial maintenance therapy in patients with persistent asthma uncontrolled on short-acting beta2-agonist therapy alone. Study design: A cost-effectiveness analysis was performed based on effectiveness and resource utilisation data that was prospectively collected from a randomised, double-blind, double-dummy, 12-week trial. Patients and methods: Patients (>15 years of age) who had asthma for at least 6 months. Effectiveness measurements in this analysis included improvement in forced expiratory volume in 1 second (FEV1) and symptom-free days (SFDs). Cost of asthma drug treatment as well as costs related to an asthma exacerbation were used in the cost analysis. The study assumed a payer's perspective. All costs are in 2001 US dollars. Results: Of the 423 patients eligible for the study, 211 were randomised to salmeterol/fluticasone propionate and 212 to montelukast. Treatment with salmeterol/fluticasone propionate resulted in a significantly higher proportion of patients who achieved a 12% increase in FEV1 (successful treatment) [salmeterol/fluticasone propionate: 71% vs montelukast: 39%; p < 0.001] and percentage of SFDs (salmeterol/fluticasone propionate: 46.8% vs montelukast: 21.5%; p < 0.001) compared with montelukast. The mean daily costs per successfully treated patient were lower in the salmeterol/fluticasone propionate group ($US5.03, 95% CI $US4.61 to $US5.50) compared with the montelukast group ($US8.25, 95% CI $US6.98 to $US9.93). Furthermore, per patient mean daily cost per SFD was lower with salmeterol/fluticasone propionate ($US7.63, 95% CI $US6.90 to $US8.50) compared with montelukast ($US14.89, 95% CI $US12.36 to $US17.98). Incremental cost-effectiveness ratios (ICERs) showed that the additional costs to achieve these benefits with salmeterol/fluticasone propionate were minimal. With regards to improvement in lung function, the ICER was $US1.33 (95% CI $US0.80 to $US2.02) and with regards to SFD, the ICER was $US1.69 (95% CI $US1.01 to $US2.48). Sensitivity analysis demonstrated the stability of the results over a range of assumptions. Conclusions: From a third-party payer perspective, this analysis shows that based on increased efficacy and only a slight increase in cost, twice-daily treatment with salmeterol/fluticasone propionate is more cost effective than once-daily treatment with montelukast as initial maintenance therapy for persistent asthma. This finding complements the results of the clinical analyses indicating that treatment of both inflammation and bronchoconstriction with products such as salmeterol/ fluticasone propionate may be more cost effective as initial maintenance asthma therapy than the use of leukotriene modifiers such as montelukast.