Clinical Citations: Inhaled steroids: Does the risk of osteoporosis reduce cost-effectiveness?

Although inhaled corticosteroids play a major role in the management of asthma, their effects on bone mineral density (BMD) are a concern for some patients. Fuhlbrigge and associates evaluated the cost-effectiveness of such therapy in light of the potential adverse effects on BMD. They found that inhaled corticosteroid therapy compares favorably with other standard medical interventions. However, the use of high doses over an extended period can affect overall costs and health.

The authors developed a mathematical simulation model to estimate clinical outcomes and costs in a group of women with mild to moderate asthma. The model allowed assessment of the range of parameters that appear to influence the relationship between inhaled corticosteroids and BMD. The analysis was done for different scenarios based on certain assumptions, such as a regimen of 200 µg twice a day and a literature-based average effect of inhaled corticosteroids on BMD.

When the analysis considered a 10-year time horizon, the results indicated a minimal increase in the costs attributed to hip fracture and an incremental cost-effectiveness ratio of $26,000 per quality-adjusted life-year and $14 per symptom-free day gained. When the analysis included a longer time horizon (over a lifetime), the incremental cost-effectiveness ratio increased to $42,000 per quality- adjusted life-year. The impact of inhaled corticosteroid therapy on BMD markedly affected cost-effectiveness only in a scenario characterized by high-dose therapy, a lifetime horizon, and a substantial effect of inhaled corticosteroids on BMD.

The authors acknowledge that the cost-effectiveness of inhaled corticosteriod therapy depends on assumptions about the impact of these drugs on BMD and the resulting risk of fracture. They conclude that to minimize the risks, it is important to use the lowest effective dose of an inhaled corticosteroid and to identify high-risk patients.