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Premedication prior to PEG-asparaginase is cost-effective in pediatric patients with acute lymphoblastic leukemia
Meghan McCormick1, Jillian Lapinski2, Erika Friehling1
1University of Pittsburgh, Pittsburgh, Pennsylvania.
Insights
Premedication and monitoring reduce Erwinia substitutions in pediatric acute lymphoblastic leukemia (ALL) treatment, proving cost-effective. This strategy improves outcomes and is favored in most analyses.
Area of Science:
- Pediatric Oncology
- Pharmacoeconomics
- Clinical Immunology
Background:
- PEG-asparaginase is crucial for pediatric acute lymphoblastic leukemia (ALL) but is highly immunogenic, often requiring substitution with Erwinia.
- Erwinia asparaginase is linked to increased costs, dosing frequency, and limited availability.
- Premedication strategies may mitigate allergic reactions to asparaginase.
Purpose of the Study:
- To evaluate the cost-effectiveness of premedication combined with therapeutic drug monitoring (TDM) for asparaginase therapy in pediatric B-ALL.
- To compare this strategy against TDM alone and no premedication/TDM.
- To assess outcomes including Erwinia substitutions and quality-adjusted life years (QALYs) from a societal perspective.
Main Methods:
- A Markov model was utilized to simulate two scenarios: standard-risk (SR) and high-risk (HR) B-ALL patients.
- Costs included asparaginase, premedication, TDM, clinic visits, and parental lost wages.
- Sensitivity analyses (probabilistic and one-way) were performed to assess model uncertainty over a five-year horizon.
Main Results:
- Premedication with monitoring was the least costly strategy in both SR and HR scenarios.
- This approach reduced Erwinia substitutions by 8% (SR) and 7% (HR) compared to TDM alone.
- Premedication yielded the most QALYs gained in SR patients and was favored in over 87% of probabilistic sensitivity analysis iterations.
Conclusions:
- Premedication combined with asparaginase level monitoring is a potentially cost-saving strategy for pediatric B-ALL.
- This approach can reduce reliance on Erwinia asparaginase and improve patient outcomes.
- The findings support the implementation of premedication and monitoring in ALL treatment protocols.
Background:
PEG-asparaginase is critical in pediatric acute lymphoblastic leukemia (ALL) therapy but is highly immunogenic. Severe allergic reactions lead to substitution of further PEG-asparaginase with Erwinia. Erwinia is associated with more frequent dosing, increased expense, and limited availability. Premedication may reduce rates of allergic reactions.
Procedures:
This Markov model evaluated the cost-effectiveness of three strategies: premedication plus therapeutic drug monitoring (TDM), TDM alone, and no premedication or TDM. We modeled two scenarios: a standard-risk (SR) B-ALL patient receiving two asparaginase doses and a high-risk (HR) patient receiving seven asparaginase doses. The model incorporated costs of asparaginase, premedication, TDM and clinic visits, and lost parental wages associated with each additional Erwinia dose. We incorporated a five-year time horizon with a societal perspective. Outcomes were Erwinia substitutions avoided and differences in quality-adjusted life years (QALYs). Probabilistic and one-way sensitivity analyses evaluated model uncertainty.
Results:
In both scenarios, premedication was the least costly strategy. In SR and HR scenarios, premedication with monitoring resulted in 8% and 7% fewer changes to Erwinia compared with monitoring alone and 3% and 2% fewer changes compared with no premedication/monitoring, respectively. Premedication resulted in the most QALYs gained in the SR patients. Individual variation of model inputs did not change premedication/monitoring favorability for either scenario. In probabilistic sensitivity analyses, premedication/monitoring was favored in >87% of iterations in both scenarios.
Conclusion:
Compared with other strategies, premedication use and asparaginase level monitoring in children with B-ALL is potentially cost-saving.
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