厄贝沙坦治疗中国高血压性2型糖尿病伴有微蛋白尿症患者的成本-效果分析

目的 :预测不同治疗方案对高血压性2型糖尿病伴有微蛋白尿症患者终末期肾病累计发病率的影响 ,以供决策者参考。方法 :用一个同行评议的Markov模型来模拟从微蛋白尿症到肾病 ,双倍血清肌酐 ,终末期肾病及包含所有死因的伴有微蛋白尿的高血压性糖尿病患者的死亡率。对3种治疗方案进行比较 :(1)早期服用厄贝沙坦 (患者伴有微蛋白尿症时即治疗 ) ;(2)晚期服用厄贝沙坦 (患者已有肾病 ) ;(3)标准的高血压治疗。在1个千例患者的假设队列中预测终末期肾病成本、期望寿命和累计发病率。特异治疗的进展和死亡几率从已发表的试验报道中引证 ,包括IRMA -2(微蛋白尿症临床试验 )和IDNT(显性肾病临床试验 )。成本从国内已发表的文献中获得。计算时间跨度为25年。未来的成本和期望寿命计算时用3 %的年贴现率。结果 :与标准高血压治疗对照组比较 ,早期服用厄贝沙坦可降低终末期肾病累计发病率8 %～22 % ,节省费用30348元 (RMB)或相当于3667美元 ,每个治疗患者可延长0. 638寿命年。晚期服用厄贝沙坦次于早期服用但优于对照。盈亏平衡点发生在服用厄贝沙坦13年后。结论 :早期治疗伴有微蛋白尿症的高血压性2型糖尿病患者预测可降低终末期肾病发病率 ,减少成本 ,延长寿命。晚期治疗仍有一定的效果。

The Cost-Effectiveness Analysis of Irbesartan in the Treatment of Hypertensive Type 2 Diabetic Patients with Microalbuminuria in China

OBJECTIVE:To evaluate the cumulative incidence of end-stage renal disease(ESRD)in Chinese hypertensive type2diabetic patients with microalbuminuria(DHM)treated with different regimes,and to provide reference for decision makers.METHODS:A peer-reviewed Markov model that simulated progression from microalbuminuria to nephropathy,douˉbling of serum creatinine,ESRD,and all-cause mortality in patients with DHM was adapted to China.Three strategies were compared:(1)early use of irbesartan(i.e.prompt treatment in subjects with microalbuminuria);(2)late use of irebesartan(i.e.as from overt nephropathy);(3)standard hypertension care(with comparable blood pressure control).Cumulative incidence of ESRD,costs and life expectancy were projected for a hypothetical cohort of1000subjects.Treatment-specific progression and mortality probabilities were derived from published trials:IRMA-2(in microalbuminuria)and IDNT(in overt nephropathy).Medical management and cost data per state were obtained from published local sources.A flexible time horizon up to25years and third party payer perspective were used.Future costs and LE were discounted at3%yearly.RESULTS:When compared with standard blood pressure control,early use of irbesartan was evaluated to reduce the cumulative incidence of ESRD from(mean±standard deviation)8%to22%,save RMB30348(US＄3667),and add0.638life years per treated patient.Late use of irbesartan was dominant over control group but dominated by early irbesartan.Break-even occurred after13years.CONˉCLUSION:Treating DHM patients by early use of irbesartan is evaluated to reduce the incidence of ESRD,extend life and reduce costs.Treating patients at a later stage is still beneficial,however to a lower extent.