James Avoka Asamani*
Background: Over the years, Angiotensin-converting enzyme inhibitors (ACEis) and Angiotensin Receptor Blockers (ARBs) have been the groups of medications of choice for managing Chronic Heart Failure (CHF). However, Entresto™, a formulation of Sacubitril and Valsartan has shown to be of superior effectiveness and thus, approved for use in many countries. Nonetheless, there is a limited economic evaluation of Entresto™ in Low-and-Middle Income Countries (LMICs), leaving significant gaps in the body of evidence supporting its cost-effectiveness.
Objective: To model the lifetime cost-effectiveness of Entresto™ as compared to Enalapril in the treatment of a cohort of 42-year old patients with stage II-IV CHF with reduced ejection fraction, from the health system perspective.
Methods: A three-state Markov model was developed to simulate the long-term outcomes and costs of care for a hypothetical cohort of 42-year-old patients with CHF who were assumed to receive either Entresto™ plus recommended therapy or Enalapril plus recommended therapy (standard care). One-way sensitivity analysis was conducted using a best and worst case scenario analysis while probabilistic sensitivity analysis was done using beta distribution around the input parameters.
Results: The results show that after 30 years, more patients taking Enalapril died as compared with those taking Entresto™ (85.3% vs. 96.5%) but the lifetime cost of Entresto™ treatment was higher than Enalapril [US$44,656.13 (GH¢192,021.35) vs. US$922.99 (GH¢3,968.86)]. Also, Entresto™ as compared with Enalapril, yielded higher QALYs (7.59 vs. 5.33) culminating in an Incremental Cost Effectiveness Ratio (ICER) of US$19,343 (GH¢83,175.08) per QALY which may be deemed not cost-effective based on an assumed Willingness to Pay (WTP) threshold of US$5,121 (three times Gross Domestic Product Per Capita).
Conclusion: In the context of Ghana, with maximum WTP threshold of US$5,121 per QALY (threefold per capita GDP), Entresto™ is not deemed a cost-effective alternative to Enalapril unless its US market price of US$380 per monthly pack is reduced by at least 73% or the WTP threshold is raised above US$10,000 per QALY. The National Health Insurance Authority (NHIA) and the Ghana National Drugs Programme (GNDP) should consider engaging the manufacturers of Entresto™ for a possible price reduction or secure a subsidy from the government or both to make the drug available for Ghanaian CHF patients.