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. Author manuscript; available in PMC: 2016 Nov 4.
Published in final edited form as: Osteoporos Int. 2011 Nov 16;23(7):2063–2065. doi: 10.1007/s00198-011-1830-8

Comment on: cost-effectiveness of denosumab for the treatment of postmenopausal osteoporosis

B Jönsson 1,✉, O Ström 2, J A Eisman 3, A Papaioannou 4, E S Siris 5, A Tosteson 6, J A Kanis 7
PMCID: PMC5096933  CAMSID: CAMS6157  PMID: 22086308

Dear Editor

In Jonsson et al. [1], the relative risks (RRs) of fracture in a population with a T-score at or below a given threshold (e.g. ≤2.5 SD) were estimated as the average for all women at or below the threshold. For greater accuracy, the estimate might consider the average RR of fracture in a population with a T-score at or below the threshold and of the same age as the population in the analysed scenario (e.g. 70-year-old women). We have, therefore, revised the estimate of RRs at or below a T-score threshold. RRs of hip, vertebral, wrist and other fractures at model entry were updated from 2.33, 2.66, 1.46, 1.71 to 3.36, 3.19, 1.60 and 1.92, respectively, for the base case scenario. The proportion of 70-year-old women who are below a given BMD threshold will have a lower mean BMD than the corresponding proportion of all women, which increases the estimated RR of fracture. This consequently favours the comparator with the highest antifracture efficacy in each comparison. Note that the RR estimated at a specific T-score is not affected. The re-estimate affects Tables 4 and 5 and Figs. 2, 3, 5, the revised versions of which are shown here. The conclusions of the original manuscript [1] remain unchanged.

Table 4.

Base–case analysis for incremental cost-effectiveness (cost per life year and QALY gained)

Denosumab vs. no treatment Denosumab vs. generic alendronate Denosumab vs. risedronate Denosumab vs. strontium ranelate
Costs/patient (€)
 Morbidity cost difference −2,181 −1,148 −1,403 −1,664
 Treatment cost differencea 1,868 1,529 1,055 939
 Cost in added life years 1,087 649 745 768
 Total cost difference 774 1,030 397 43
Avoided fractures during 10 years/1,000 patients
 Hip fractures −39 −20 −26 −32
 Vertebral fractures −62 −41 −45 −43
 NNT to avoid one hip fracture 26 50 39 32
 NNT to avoid one vertebral fracture 17 25 23 24
QALYs and life years/patient
 Life years gained (undiscounted) 0.068 0.040 0.046 0.048
 Life years gained (discounted) 0.047 0.028 0.032 0.033
 QALYs gained 0.084 0.049 0.057 0.060
 Cost/life year gained 16,531 37,082 12,409 1,290
 Cost per QALY gained (excluding CIALY) Cost saving 7,764 Cost saving Cost saving
 Cost per QALY gained 9,250 20,976 6,998 710
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Women aged 71 years with a T-score at or below −2.5 SD and 34% prevalence of prior vertebral fracture

NNT number needed to treat

a

Including monitoring costs

Table 5.

Other sensitivity analyses (€/QALY)

Scenario Denosumab vs. no treatment Denosumab vs. generic alendronate Denosumab vs. risedronate Denosumab vs. strontium ranelate
Base–casea 9,250 20,976 6,998 710
Discount rates (5%) 9,576 22,622 6,868 133
Discount rates (0%) 9,414 19,285 7,793 2,139
One year DAPS persistence 10,656 28,501 8,548 214
Perfect persistence for all treatments 6,902 58,449 6,817 Cost saving
Denosumab maximum offset time 2 years 14,157 33,103 14,254 6,278
All treatments maximum offset time 2 years 14,157 27,970 11,897 5,127
10-year modelling horizon 5,484 22,422 1,454 Cost saving
GIAEsb for alendronate/risedronate 20,976 6,998 –
Disutility from fractures decreased by 10% 9,819 22,256 7,426 755
20% of excess mortality attributable to fractures 4,886 18,231 2,267 Cost saving
10 year treatment duration 8,758 21,455 6,457 Cost saving
Mortality after hip and vertebral fractures 3 years 6,084 18,780 3,475 Cost saving
Mortality after hip and vertebral fractures 5 years 8,157 20,182 5,766 Cost saving
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a

The base case assumed discount rates of 3%, improved persistence for 3 years, max offset time of 5 years for all treatments, life-time horizon, no adverse events for any treatment, 5-year maximum treatment duration, 8 years of increased post-fracture mortality after hip and vertebral fractures

b

Gastrointestinal adverse events

Fig. 2.

Fig. 2

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Effect of variations in persistence of denosumab on incremental cost-effectiveness of denosumab versus comparators for the base case population

Fig. 3.

Fig. 3

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Number of avoided fracture/1,000 patients from the base case population according to differences in persistence between denosumab and alendronate

Fig. 5.

Fig. 5

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The effect of age at start of treatment with or without a prior fracture (T-score at or below −2.5 SD) on the cost-effectiveness of denosumab vs. comparators

Contributor Information

B. Jönsson, Stockholm School of Economics, Box 6501, 11383, Stockholm, SE, Sweden

O. Ström, Geriatrics and Medicine, McMaster University, Main St W, 1280, Hamilton, ON, Canada

J. A. Eisman, Geriatrics and Medicine, McMaster University, Main St W, 1280, Hamilton, ON, Canada

A. Papaioannou, Geriatrics and Medicine, McMaster University, Main St W, 1280, Hamilton, ON, Canada

E. S. Siris, Geriatrics and Medicine, McMaster University, Main St W, 1280, Hamilton, ON, Canada

A. Tosteson, Geriatrics and Medicine, McMaster University, Main St W, 1280, Hamilton, ON, Canada

J. A. Kanis, Geriatrics and Medicine, McMaster University, Main St W, 1280, Hamilton, ON, Canada

References

  • 1.Jonsson B, Strom O, Eisman JA, Papaioannou A, Siris ES, Tosteson A, Kanis JA. Cost-effectiveness of denosumab for the treatment of postmenopausal osteoporosis. Osteoporos Int. 2010;22(3):967–982. doi: 10.1007/s00198-010-1424-x. [DOI] [PMC free article] [PubMed] [Google Scholar]

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