Oral versus Intravenous Iron for Anemia in Pregnancy: A Cost-Effectiveness Analysis

Pregnancy is associated with increased risk for the development of iron deficiency anemia. Pregnant patients with anemia are at increased risk for significant morbidity and mortality. Iron therapies for the correction of anemia during pregnancy are available in intravenous and oral formulations; however, the cost-effectiveness of these therapies in the United States has not been previously evaluated. The objective of this study is to estimate the cost-effectiveness of oral and intravenous iron therapies as treatments for prepartum anemia in the United States.We constructed a Markov decision-analytic model to evaluate the cost-effectiveness of three common therapies for repleting iron in patients with prepartum anemia in the United States: oral iron, intravenous iron sucrose, and intravenous ferric carboxymaltose. Each strategy differentially modified the proportion of patients with anemia at time of delivery by the therapeutic efficacy of each treatment option demonstrated in the literature. Outcomes of interest included net costs, quality-adjusted life-years, and adverse outcomes averted. Costs were considered from the health system and societal perspectives over a lifetime time horizon for a hypothetical cohort of 3.8 million pregnant patients. Deterministic and Monte Carlo probabilistic sensitivity analyses were conducted to evaluate the robustness of the model.All iron therapies were dominant versus the "do nothing" strategy in the majority of simulations, implying that they were simultaneously more effective and cost-saving. Ferric carboxymaltose produced the most favorable results overall, with $696,920,137 in cost-savings and 26,660 postpartum hemorrhage cases, 888 hysterectomies, and 43 postnatal suicides averted per cohort. Threshold analysis suggested that oral iron was cost-saving below a threshold of $14.40 per 325 mg, and iron sucrose and ferric carboxymaltose were cost-saving below thresholds of $1996.86 and $2,893.97 per course, respectively.Our findings suggest that treating prepartum anemia with currently available iron therapies would result in significant cost-savings and reductions in adverse outcomes associated with anemia in this context. Ferric carboxymaltose likely confers the greatest overall benefit among competing options. This conclusion is robust to parameter uncertainty, even when the cost of these therapies is significantly higher than demonstrated in the literature. · Oral and intravenous iron therapies are likely cost-effective for the treatment of antepartum anemia.. · Intravenous ferric carboxymaltose is likely the most clinically and economically favorable treatment.. · This is the first U.S. estimate of the cost-effectiveness of oral and intravenous iron for antepartum anemia..