A cost-effectiveness analysis of patiromer in the UK: evaluation of hyperkalaemia treatment and lifelong RAASi maintenance in chronic kidney disease patients with and without heart failure

Abstract

Background: Chronic kidney disease (CKD) patients with and without heart failure (HF) often present with hyperkalaemia (HK) leading to increased risk of hospitalisations, cardiovascular related events and cardiovascular-related mortality. Renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, the mainstay treatment in CKD management, provides significant cardiovascular and renal protection. Nevertheless, its use in the clinic is often suboptimal and treatment is frequently discontinued due to its association with HK. We evaluated the cost-effectiveness of patiromer, a treatment known to reduce potassium levels and increase cardiorenal protection in patients receiving RAASi, in the UK healthcare setting.

Methods: A Markov cohort model was generated to assess the pharmacoeconomic impact of patiromer treatment in regulating HK in patients with advanced CKD with and without HF. The model was generated to predict the natural history of both CKD and HF and quantify the costs and clinical benefits associated with the use of patiromer for HK management from a healthcare payer's perspective in the UK.

Results: Economic evaluation of patiromer use compared to standard of care (SoC) resulted in increased discounted life years (8.93 versus 8.67) and increased discounted quality-adjusted life years (QALYs) (6.36 versus 6.16). Furthermore, patiromer use resulted in incremental discounted cost of £2,973 per patient and an incremental cost-effectiveness ratio (ICER) of £14,816 per QALY gained. On average, patients remained on patiromer therapy for 7.7 months, and treatment associated with a decrease in overall clinical event incidence and delayed CKD progression. Compared to SoC, patiromer use resulted in 218 fewer HK events per 1,000 patients, when evaluating potassium levels at the 5.5-6 mmol/l; 165 fewer RAASi discontinuation episodes; and 64 fewer RAASi down-titration episodes. In the UK, patiromer treatment was predicted to have a 94.5% and 100% chance of cost-effectiveness at willingness-to-pay thresholds (WTP) of £20,000/QALY and £30,000/QALY, respectively.

Conclusion: This study highlights the value of both HK normalisation and RAASi maintenance in CKD patients with and without HF. Results support the guidelines which recommend HK treatment, e.g., patiromer, as a strategy to enable the continuation of RAASi therapy and improve clinical outcomes in CKD patients with and without HF.

Keywords: Chronic kidney disease; Cost-effectiveness; Heart failure; Hyperkalaemia; Patiromer; RAASi.

Fig. 1

Model flow diagram. States highlighted in grey represent starting health states

Fig. 2

Influence of RAASi use and HK events on disease progression and events. References below each box describe the baseline probabilities/rates; references alongside arrows describe the influence of one disease component on the other, with influences applied to the baseline probabilities rates

Fig. 3

Probabilistic sensitivity analysis

Fig. 4

Impact of changes in the annual rate of HK on costs, QALYs and life years (compared to no HK incidence). All other inputs remain as in the base case cost-effectiveness analysis

Fig. 5

The impact of lifetime optimal RAASi management (compared to no RAASi use) and the association of outcomes with patient’s baseline age, starting CKD stage and HF disease status. A: Total per-patient discounted costs in patients with CKD and HF; B: Total per-patient discounted costs in patients with CKD without HF; C: Total per-patient discounted QALYs in patients with CKD and HF; D: Total per-patient discounted QALYs in patients with CKD without HF; Note: All other inputs remain as in the base case cost-effectiveness analysis