A Cost-Effectiveness Comparison of Desipramine, Gabapentin, and Pregabalin for Treating Postherpetic Neuralgia

Alec B. O'Connor MD; Katia Noyes PhD, MPH; Robert G. Holloway MD, MPH

Disclosures

J Am Geriatr Soc. 2007;55(8):1176-1184. 

In This Article

Abstract and Introduction

Abstract

Objectives: To compare the net health effects and costs resulting from treatment with different first-line postherpetic neuralgia (PHN) medications.
Design: Cost–utility analysis using published literature.
Participants: Hypothetical cohort of patients aged 60 to 80 with PHN.
Interventions: Desipramine 100 mg/d, gabapentin 1,800 mg/d, and pregabalin 450 mg/d.
Measurements: A decision model was designed to describe possible treatment outcomes, including different combinations of analgesia and side effects, during the first 3 months of therapy for moderate to severe PHN. The main outcome was cost per quality-adjusted life-year (QALY) gained. Costs were estimated using the perspective of a third-party payer. Multivariate, univariate, and probabilistic sensitivity analyses were performed, and the time frame of the model was varied to 1-month and 6-month horizons.
Results: Desipramine was more effective and less expensive than gabapentin or pregabalin (dominant) under all conditions tested. Gabapentin was more effective than pregabalin but at an incremental cost of $216,000/QALY. Below $140/month, gabapentin became more cost-effective than pregabalin at a threshold of $50,000/QALY, and below $115/month gabapentin dominated pregabalin.
Conclusion: Desipramine appears to be more effective and less expensive than gabapentin or pregabalin for the treatment of older patients with PHN in whom it is not contraindicated. After its price falls, generic gabapentin will likely be more cost-effective than pregabalin.

Introduction

Approximately one-fourth of all Americans will develop herpes zoster during their lifetimes, and 10% to 33% of these cases will result in postherpetic neuralgia (PHN).[1] PHN occurs primarily in older adults[2] and is associated with substantial reductions in quality of life and function.[3,4]

The management of PHN is expensive,[5] and patients often continue to have severe pain despite taking prescribed analgesics.[3,4] The best initial therapy for patients is unknown, because there have been no head-to-head randomized controlled trials (RCTs) of the first-line medications.[6,7] Recent systematic reviews of treatment options for PHN[6] and peripheral neuropathic pain[7] have concluded that tricyclic antidepressants are the most efficacious option, but when the potential for side effects is included in decision-making, tricyclic antidepressants, gabapentin, and pregabalin are all considered first-line treatment options.[7]

Gabapentin is currently the most commonly prescribed neuropathic pain medication for PHN and other neuropathic pain conditions[3,4,8,9] despite costing several times more than tricyclic antidepressants. Amitriptyline continues to be the most commonly prescribed tricyclic antidepressant for older patients with PHN,[3,4,8] even though its use is considered inappropriate in older people because of the risk of serious side effects.[10,11,12,13,14,15] Desipramine and nortriptyline have equivalent efficacy but fewer anticholinergic and adrenergic side effects;[16,17,18,19,20,21,22] the American Geriatrics Society has recommended them as an appropriate treatment option,[23] but they are underused in PHN.[3,4]

This analysis used existing RCT data and decision-analytic modeling to compare the costs and net treatment effects that result from treating moderate to severe PHN in older patients with desipramine, gabapentin, or pregabalin.

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