Cost-effectiveness of frontline eltrombopag with immunosuppressive therapy for severe aplastic anemia

The randomized phase 3 RACE trial demonstrated eltrombopag used in conjunction with traditional immunosuppressive therapy (IST) to be an efficacious treatment for severe aplastic anemia. However, eltrombopag can pose a significant cost burden. Using clinical data from the RACE trial, we performed the first cost-effectiveness analysis of frontline eltrombopag plus IST in adults with newly diagnosed severe aplastic anemia across all accepted willingness-to-pay (WTP) thresholds from the United States modified societal perspective. The primary outcome was the incremental net monetary benefit across WTP thresholds of $50,000-$150,000/quality-adjusted life year (QALY) with base-case WTP threshold of $120,000/QALY. Frontline eltrombopag plus IST versus frontline IST alone accrued discounted costs of $593,000 and $561,000, and discounted QALYs of 11.53 and 10.73, respectively, with a per-patient incremental net monetary benefit of $64,000 [95% credible interval -$91,000 to $262,000] favoring frontline eltrombopag plus IST. Deterministic sensitivity analyses demonstrated that the 6-month overall response risk ratio (with versus without frontline eltrombopag) had the greatest effect on model results. In probabilistic sensitivity analysis, frontline eltrombopag with IST was favored in 78% of 10,000 second-order Monte Carlo iterations, as well as 58% and 82% of 10,000 iterations at WTPs of $50,000 and $150,000/QALY, respectively. At current pricing, frontline eltrombopag is the cost-effective therapeutic strategy in adults with severe aplastic anemia in the US. Longer-term clinical and patient utility data will likely help further clarify the cost-effectiveness of eltrombopag in this setting.