Excerpt
Apomorphine (Movapo) is a dopamine agonist indicated in Canada for the acute, intermittent treatment of hypomobility “off” episodes (“end-of-dose wearing off” and unpredictable “on/off” episodes) in patients with advanced Parkinson’s disease (PD). It is available in 3 mL (30 mg) pre-filled disposable multi-dose pens for subcutaneous injection at a submitted price of $42.95 per pen or $1.43 per mg. The recommended starting dose of apomorphine is 0.2 mL (2 mg) as needed to treat recurring “off” episodes, to be titrated by 0.1 mL (1 mg) every few days on the basis of effectiveness and tolerance up to a maximum dose of 0.6 mL (6 mg). The total daily dose should not exceed 2 mL (20 mg). Apomorphine pens should be discarded 48 hours after first use. A non-5HT3 antagonist concomitant antiemetic should be started at least two days prior to the initial dose of apomorphine and continued based on dosing recommendations for the antiemetic, and reassessed periodically.
The manufacturer submitted a cost-utility analysis comparing apomorphine (with concomitant domperidone) as an adjunct to standard of care (SoC) oral therapy versus SoC alone for the treatment of “off” episodes in patients with advanced PD. The manufacturer’s base case was a probabilistic analysis conducted from the perspective of a Canadian health care payer over a five-year time horizon, with costs and benefits after one year discounted at a rate of 1.5%. The model consisted of four “off” health states based on quartiles of waking time spent in “off” state and death. Patients entered the model in one of the four health states. Those in the apomorphine group transitioned toward a less severe “off” state after the first one-year cycle based on the findings of a published systematic review, while those in the SoC group remained in their original “off” state. With the exception of mortality, no transitions occurred after the first cycle. For the purpose of utility estimates and resource use, all patients were assumed to have a Hoehn and Yahr (H&Y) stage of 3.6 based on the same systematic review; H&Y stage was not otherwise considered in the model. As SoC was assumed to be the same between groups, only adverse events (AEs) associated with apomorphine were included, with utility decrements and resource costs applied for two months in the first year of treatment.
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