Análise de custo-efetividade dos imunossupressores utilizados no tratamento de manutenção do transplante renal

Abstract

Introduction: chronic kidney disease stands out as affecting the lives of thousands of Brazilians and burdening the public coffers. In the terminal phase of the disease, the survival of the patient is conditioned to a type of substitutive renal therapy. The literature has demonstrated that kidney transplantation is the cost-effective alternative among the substitutive renal therapies, since it allows reintegration of the patient into their daily activities, increasing the expectation and quality of life. One factor that has contributed to the success of kidney transplantation is the technological advancement of immunosuppressants. The administration of three-drug regimens consisting of a steroid plus two drugs of different pharmacological classes (calcineurin inhibitors or antimetabolites or inhibitors of rapamycin) is recommended for the maintenance treatment of kidney transplantation. Aim: to evaluate the cost-effectiveness of administration of tacrolimus with mycophenolate sodium and prednisone (Group 1 = 93 patients) compared to the combination of tacrolimus with everolimus and Prednisone (Group 2 = 91 patients) in post-transplant renal maintenance, in an Integrated Practice Unit of the Santa Casa de Misericórdia Hospital of Juiz de Fora, Minas Gerais. Material and methods: for the pharmacoeconomic analysis of the immunosuppressive regimens, the static model, of the decision tree type, was used. The model was developed in the Treeage Suite 2011 software and followed a cohort of renal transplant recipients, estimating the clinical benefits in terms of survival and incidence of adverse events (rejection, cytomegalovirus disease / infection, graft loss and death), as well as the costs associated with immunosuppressive regimens, from the Unified Health System perspective. Results: the efficacy of everolimo in relation to mycophenolate sodium was mainly present in the events related to the incidence of patients who presented infection or disease due to cymegalovirus (4.4% with everolimo versus 20.4% with mycophenolate sodium, p = 0.001). In the analysis considering survival as an outcome, Group 2 can not be considered cost-effective when compared to Group 1 use, as the incremental Cost-Effectiveness Ratio was around R$229,876.30, exceeding the cost thresholdeffectiveness recommended by the World Health Organization, three times the Brazilian GDP. In the analysis related to the incidence of adverse events, the ICR was around R$52,760.52, therefore, Group 2 was considered cost-effective in relation to Group 1. Conclusion: the immunosuppressive regimen containing mycophenolic acid is still considered the gold standard for the maintenance treatment of kidney transplantation, however, is associated with many adverse effects for transplant recipients. This study demystifies this regimen, as the immunosuppressive regimen containing everolimo was cost-effective in relation to mycophenolate in the analysis made from the incidence of adverse effects, as well as in the significant reduction of events related to citamegalovirus, which is responsible the greatest cause of morbidity and mortality in transplant patients.