Epoetin Beta with Intravenous Iron Results in Overall Cost Savings in a Population of Anemic Patients with Lymphoid Malignancies Not Receiving Chemotherapy.
Authors: Hedenus Michael , Näsman Per 
Published: October 2019

Abstract
Erythropoiesis-stimulating agents (ESAs) provide effective treatment for anemia in patients with cancer, but studies suggest that response rates can vary from 50 to 80%. One major reason why a patient may fail to respond to an ESA is functional iron deficiency (FID), defined as a failure to provide iron rapidly enough to meet the needs of erythropoiesis, despite the presence of sufficient iron stores. Consequently, concomitant intravenous (IV) iron supplementation has the potential to improve response to ESAs, thereby, allowing a decrease in dose requirements. A recent study of 67 anemic (hemoglobin [Hb] 9–11 g/dL) patients with lymphoid malignancies not receiving chemotherapy evaluated the Hb response (defined as an increase in Hb of ≥2 g/dL without transfusion up to Week 15) to epoetin beta 30 000 IU Once Weekly with or without IV iron sucrose (Hedenus et al. Leukemia.2007;21:627–632). Patients were iron replete at baseline, as shown by the presence of stainable iron in the bone marrow. This analysis aimed to investigate whether use of epoetin beta and IV iron is cost-effective compared with epoetin beta without IV iron, based on the results of this study. The analysis was performed from a Swedish societal perspective based on differences in overall costs (drug costs, laboratory tests and resource use) and differences in effect (Hb increase) during 16 weeks’ treatment with epoetin beta with or without IV iron. All costs are presented in 2006 Swedish Kronor (SEK). In normal practice in Sweden, IV iron is administered by a nurse in an outpatient setting. Therefore, resource costs in this analysis included an estimate of costs of nurse time and all materials required for administration of IV iron, as well as the cost of travel to the clinic for the patient. Since 20% of patients attend with a companion, an estimate of the cost of loss of companion work time for 20% of visits was also included. In contrast, epoetin beta is usually self-administered in Sweden; thus, no resource costs for epoetin beta administration were included. In the intention-to-treat population (n=67), the Hb increase (mean 2.76 g/dL versus 1.56 g/dL, respectively; p=0.0002) and Hb response rate (87% versus 53%, respectively; p=0.0014) were significantly greater in patients receiving epoetin beta with IV iron compared with patients receiving epoetin beta without IV iron. Total cumulative dose of epoetin beta over the course of the study was lower in the epoetin beta with IV iron group (532 000 IU) than in the epoetin beta without IV iron group (629 000 IU; p=0.059). Overall mean cost per patient in the epoetin beta with IV iron group was SEK 56 411 and in the epoetin beta without IV iron group was SEK 60 666. Despite the additional costs of iron administration, epoetin beta treatment with IV iron resulted in overall cost savings of ∼7% compared with epoetin beta without IV iron, mainly due to reduced ESA dosages. Treatment of anemic patients with lymphoid malignancies not receiving chemotherapy with epoetin beta and IV iron resulted in better outcomes at lower cost compared with epoetin beta without IV iron. This suggests that epoetin beta with IV iron is a dominant (or superior) therapy at least from a Swedish perspective.