Economic impact of caspofungin as compared with liposomal amphotericin B for empirical therapy in febrile neutropenia in Australia

Background In a major clinical trial, caspofungin was as efficacious as liposomal amphotericin B (LAmB) for empirical therapy in febrile neutropenia. The current study sought to evaluate the economic impact of caspofungin as compared with LAmB for febrile neutropenia in Australia. Methods A decision analytic model was developed to capture the downstream consequences of the empirical antifungal therapy. The main outcomes were success, breakthrough infection, persistent baseline infection, persistent fever, premature discontinuation and death. Underlying transition probabilities and treatment patterns were derived directly from trial data. Resource use was estimated using an expert panel. Cost inputs were obtained from the latest Australian representative sources. The perspective adopted was that of the Australian hospital system. Uncertainty and sensitivity analyses were undertaken via Monte Carlo simulation. Results Caspofungin was associated with a net cost saving of AU$7245 (12.6%) per patient over LAmB (AU$50 267 versus AU$57 512). A similar trend was observed with cost per success and death prevented (AU$24 169 and AU$7270, respectively). Caspofungin dominated LAmB as it resulted in higher efficacy and lower costs when compared with LAmB. Persistent fever was the main contributing clinical outcome to the therapeutic costs of both antifungals. The results were most sensitive to therapy duration. Monte Carlo simulation suggested a 99.8% chance for LAmB to cost more than caspofungin. Conclusions This is the first economic study to evaluate the place of caspofungin as empirical therapy in Australia. Caspofungin is more cost-beneficial than LAmB, which contradicts the current Australian guidelines of recommending LAmB as the first choice for empirical therapy.