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Randomized Controlled Trial
. 2018 Feb;178(2):415-423.
doi: 10.1111/bjd.16006. Epub 2018 Jan 15.

Doxycycline compared with prednisolone therapy for patients with bullous pemphigoid: cost-effectiveness analysis of the BLISTER trial

J M Mason  1 , J R Chalmers  2 , T Godec  3 , A J Nunn  3 , G Kirtschig  2 , F Wojnarowska  4 , M Childs  5 , D Whitham  5 , E Schmidt  6 , K Harman  7 , S Walton  8 , A Chapman  9 , H C Williams  2 ; U.K. Dermatology Clinical Trials Network BLISTER Study Group
Affiliations
Randomized Controlled Trial

Doxycycline compared with prednisolone therapy for patients with bullous pemphigoid: cost-effectiveness analysis of the BLISTER trial

J M Mason et al. Br J Dermatol. 2018 Feb.

Abstract

Background: Bullous pemphigoid (BP) is an autoimmune blistering skin disorder associated with significant morbidity and mortality. Doxycycline and prednisolone to treat bullous pemphigoid were compared within a randomized controlled trial (RCT).

Objectives: To compare the cost-effectiveness of doxycycline-initiated and prednisolone-initiated treatment for patients with BP.

Methods: Quality-of-life (EuroQoL-5D-3L) and resource data were collected as part of the BLISTER trial: a multicentre, parallel-group, investigator-blinded RCT. Within-trial analysis was performed using bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, informing a probabilistic assessment of incremental treatment cost-effectiveness from a health service perspective.

Results: In the base case, there was no robust difference in costs or QALYs per patient at 1 year comparing doxycycline- with prednisolone-initiated therapy [net cost £959, 95% confidence interval (CI) -£24 to £1941; net QALYs -0·024, 95% CI -0·088 to 0·041]. However, the findings varied by baseline blister severity. For patients with mild or moderate blistering (≤ 30 blisters) net costs and outcomes were similar. For patients with severe blistering (> 30 blisters) net costs were higher (£2558, 95% CI -£82 to £5198) and quality of life poorer (-0·090 QALYs, 95% CI -0·22 to 0·042) for patients starting on doxycycline. The probability that doxycycline would be cost-effective for those with severe pemphigoid was 1·5% at a willingness to pay of £20 000 per QALY.

Conclusions: Consistently with the clinical findings of the BLISTER trial, patients with mild or moderate blistering should receive treatment guided by the safety and effectiveness of the drugs and patient preference - neither strategy is clearly a preferred use of National Health Service resources. However, prednisolone-initiated treatment may be more cost-effective for patients with severe blistering.

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Conflict of interest statement

Competing interests: HCW is Director of the NIHR Health Technology Assessment Programme. JM, JRC, FW, GK, TRG, ES, MC, SW, KH, AC, DW, and AJN report no competing interests.

Figures

Figure 1
Figure 1. Cost-effectiveness plane: doxycycline compared to prednisolone, base case analysis (cost/QALY £, 2013)
Figure 2
Figure 2. Cost-effectiveness acceptability curve: doxycycline compared to prednisolone, base case analysis
Figure 3
Figure 3. Cost-effectiveness plane: doxycycline compared to prednisolone, subgroup analysis (cost/QALY £, 2015)
Figure 4
Figure 4. Expected value of perfect information: overall and subgroup analysis (£, 2015)
See this image and copyright information in PMC

Comment in

References

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