Abstract
Objetivo
Análisis coste-efectividad de la terapia combinada de enalapril y nitrendipino (E/N), como terapia de segunda línea para la HTA leve o moderada.
Diseño
Modelo teórico de coste-efectividad basado en las pautas de tratamiento habituales de la HTA en atención primaria, la opinión sistematizada de un panel de expertos y los costes directos de los recursos sanitarios y la adquisición de medicación.
Emplazamiento
Sistema Nacional de Salud español.
Participantes
Simulación de 1.000 pacientes hipertensos con un horizonte temporal de un año.
Intervenciones
Tras un primer fracaso del tratamiento de primera línea con enalapril o con nitrendipino, se evalúan el incremento de la dosis del tratamiento de primera línea, el cambio de fármaco y la administración de la combinación enalapril/nitrendipino.
Mediciones principales
Probabilidades de alcanzar o no el control de la presión arterial diastólica, de abandono y de aplicar una u otra estrategia en nuestro medio. Utilización de recursos sanitarios en cada situación. Costes asociados a la utilización de recursos y costes de adquisición de la medicación.
Resultados
El cociente coste-efectividad de la terapia combinada con enalapril/nitrendipino es consistentemente más eficiente que el aumento de dosis o el cambio a otro fármaco, tanto si se inicia el tratamiento con enalapril (301,06 euros frente a 337,97 y 588,42) como con nitrendipino (331,5 euros frente a 469,88 y 579,76).
Conclusiones
La terapia combinada (E/N) es una opción terapéutica eficiente, según los supuestos considerados en el modelo y, por tanto, recomendable para su prescripción.
Palabras clave: Hipertensión, Enalapril, Nitrendipino, Terapia combinada, Análisis coste-efectividad
Abstract
Objective
Cost-effectiveness analysis of combined enalapril-nitrendipine therapy (E/N), as second-line therapy for light or moderate hypertension.
Design
Theoretical model of costeffectiveness, based on the norms of hypertension treatment in primary care, the considered view of a panel of experts and the direct costs of health resources and purchase of medication.
Setting
Spanish National Health system.
Participants
Simulation of 1000 patients with hypertension, with a time horizon of one year.
Interventions
After a prior failure of the firstline treatment with either enalapril or nitrendipine, an evaluation was made of the possibilities of increasing dosage of the firstline treatment, changing the drug or administering the E/N combination.
Main measurement
The likelihoods, in the primary care context, of controlling diastolic pressure, of abandonment and of using the two strategies or not were measured, as were the use of health resources in each situation, and costs of resource use and of medication.
Results
The cost-effectiveness quotient of the combined E/N treatment was consistently more efficient than the increase in dose or change to another drug. This was so, whether the treatment was started with enalapril (301.06 euros vs 337.97 euros and 588.42 euros) or with nitrendipine (331.5 euros vs 469.88 euros and 579.76 euros).
Conclusions
Combined therapy (E/N) is, on the basis of the assumptions made in the model, an efficient therapy option. Therefore, it can be recommended for prescription.
Key words: Hypertension, Enalapril, Nitrendipine, Combined therapy, Costeffectiveness analysis
Bibliografía
- 1.Banegas J.R., Rodríguez-Artalejo F., Graciani A., Villar F., Guallar- Castillon P., De la Cruz J. Epidemiología de la hipertensión arterial en España. Prevalencia, conocimiento y control. Hipertensión. 1999;16:315–322. [Google Scholar]
- 2.Plans-Rubio P. Cost-effectiveness of cardiovascular prevention program in Spain. Int J Technol Assess Health Care. 1998;14:320–330. doi: 10.1017/s0266462300012289. [DOI] [PubMed] [Google Scholar]
- 3.González J., Llinás M., Rodríguez F., Salazar F. Efectos de la administración de un IECA y un antagonista del calcio en hipertensión. Hipertensión. 1997;14:137–140. [Google Scholar]
- 4.1999 World Health Organization-International Society of Hypertension Guidelines for the management of hypertension. Guidelines Subcommittee. J Hypertens. 1999;17:151–183. [PubMed] [Google Scholar]
- 5.Skolnik N.S., Beck J.D., Clark M. Combination antihypertensive drugs: recommendation for use. Am Fam Phys. 2000;61:3049–3056. [PubMed] [Google Scholar]
- 6.Latts L. Impact of combination therapy on managed care. Am J Manag Care. 1999;5(Suppl 7):456–462. [PubMed] [Google Scholar]
- 7.Hillerman D. Cost effectiveness of combination therapy. Am J Manag Care. 1999;5(Suppl 7):449–455. [PubMed] [Google Scholar]
- 8.The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of high blood pressure Arch Intern Med. 1997;157:2413–2446. doi: 10.1001/archinte.157.21.2413. [DOI] [PubMed] [Google Scholar]
- 9.Reverte-Cejudo D., Moreno Palomares J.J., Ferreira Pasos E.M. Hipertensión arterial: actualización de su tratamiento. Inf Ter Sist Nac Salud. 1998;22:81–94. [Google Scholar]
- 10.Staessen J.A., Fagard R., Thijs L., Celis H., Arabidze G.G., Birkenhager W.H., Randomised doubled-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet. 1997;350:757–764. doi: 10.1016/s0140-6736(97)05381-6. [DOI] [PubMed] [Google Scholar]
- 11.Staessen J., Thisj L., Fagard R.H., Birkenhager W.H., Arabidze G., Babeanu S. Calcium channel blockade and cardiovascular prognosis in the european trial on isolated systolic hypertension. Hypertension. 1998;32:410–416. doi: 10.1161/01.hyp.32.3.410. [DOI] [PubMed] [Google Scholar]
- 12.Wenzel U.O., Helmchen U., Schoeppe W., Schwietzer G. Combination treatment of enalapril with nitrendipine in rats with renovascular hypertension. Hypertension. 1994;1:114–122. doi: 10.1161/01.hyp.23.1.114. [DOI] [PubMed] [Google Scholar]
- 13.Weir M.R., Rosenberger C., Fink J.C. Pilot study to evaluate a water displacement technique to compare effects of diuretics and ACE inhibitors to alleviate lower extremity edema due to dihydropyridine calcium antagonists. Am J Hypertens. 2001;14:963–968. doi: 10.1016/s0895-7061(01)02167-7. [DOI] [PubMed] [Google Scholar]
- 14.Pool J., Kaihlanen P., Lewis G., Ginsberg D., Oparil S., Glazer R. Once-daily treatment of patients with hypertension: a placebo- controlled study of amlodipine and benazepril vs amlodipine or benazepril alone. J Hum Hypertens. 2001;15:495–498. doi: 10.1038/sj.jhh.1001217. [DOI] [PubMed] [Google Scholar]
- 15.González C., Sanz P., Álvarez S., Bermejo F., Gallego P., La Torre del Carmen L. Does the system of prescription insurance the therapy compliance of hypertensive patients? Aten Prim. 1999;24:281–284. [PubMed] [Google Scholar]
- 16.Mar J., Rodríguez-Artalejo F. Which is more important for the efficiency of hypertension treatment: hypertension stage, type of drug or therapeutic compliance? J Hypertens. 2001;19:149–155. doi: 10.1097/00004872-200101000-00020. [DOI] [PubMed] [Google Scholar]
- 17.Márquez-Contreras E., Casado J., Ramos J., Sáenz S., Moreno J.P., Celotti B. Influencia del cumplimiento terapéutico en los niveles de presión arterial en el tratamiento de la hipertensión arterial. Hipertensión. 1998;15:133–139. [Google Scholar]
- 18.Puigventos F., Llodra V., Vilanova M., Delgado O., Ferreruela M., Forteza-Rey J. Compliance with hypertension treatment: 10 years of publications in Spain. Med Clin (Barc) 1997;109:702–706. [PubMed] [Google Scholar]
- 19.Roca-Cusachs A., Torres F., Horas M., Ríos J., Calvo G., Delgadillo J. Nitrendipine and enalapril combination therapy in mild to moderate hypertension: assessment of dose-response relationship by a clinical trial of factorial design. J Cardiovasc Pharmacol. 2001;38:840–849. doi: 10.1097/00005344-200112000-00005. [DOI] [PubMed] [Google Scholar]
- 20.Kroning B., Pittrow D.B., Kirch W., Wezel D., Weidinger G., German Reserpine in Hypertension study Group Different concepts in first-line treatment of essential hypertension. Comparison of low-dose reserpine-thiazide combination with Nitrendipine monotherapy. Hypertension. 1997;29:651–658. doi: 10.1161/01.hyp.29.2.651. [DOI] [PubMed] [Google Scholar]
- 21.Prisant L.M., Weir M.R., Papademetriou V., Weber M.A., Adegbile I.A., Alemayehu D. Low-dose drug combination therapy: an alternative first-line approach to hypertension treatment. Am Heart J. 1995;130:359–366. doi: 10.1016/0002-8703(95)90454-9. [DOI] [PubMed] [Google Scholar]
- 22.Rovira J., Segú J.L., Figueras M., Brosa M., Artés M., Ollé A. Estudio coste-efectividad del tratamiento de la hipertensión ligera- moderada con inhibidores de la enzima convertidora de la angiotensina. Hipertensión. 1996;13:322–330. [Google Scholar]
- 23.McMurray J. The health economics of the treatment of hyperlipidemia and hypertension. Am J Hypertens. 1999;12(10 Pt 2):99–104. doi: 10.1016/s0895-7061(99)00161-2. [DOI] [PubMed] [Google Scholar]
- 24.Lindholm L., Hallgren C.G., Boman K., Margren K., Weinehall L., Ogren J.E. Cost-effectiveness analysis with defined budget: how to distribute resources for prevention of cardiovascular disease? Health Policy. 1999;48:155–170. doi: 10.1016/s0168-8510(99)00045-7. [DOI] [PubMed] [Google Scholar]