Elimination diets, PPIs most cost-effective for EoE treatment

Elimination diets were the most cost-effective strategy for treatment of eosinophilic esophagitis (EoE), a recent study found.

Researchers used a Markov model to evaluate first-line treatments for EoE: proton-pump inhibitors (PPIs) (omeprazole, 20 mg twice daily), swallowed topical steroids (budesonide, 1 mg twice daily), and the six-food elimination diet. Modeling scenarios with two- and four-food elimination diets were also examined. Incremental cost-effectiveness ratios at two- and five-year time horizons were the primary outcomes, with a willingness-to-pay threshold of $100,000 per quality-adjusted life-year. Secondary analyses included modeling from a societal perspective that accounted for patient-specific costs and a separate simplified model comparing the recently FDA-approved dupilumab to steroids and PPIs as a first-line treatment. The results were published Sept. 30 by the American Journal of Gastroenterology.

In the base-case scenario using a five-year time horizon, average costs for initial therapy were $15,296.81 for the six-food elimination diet, $16,153.77 for PPIs, and $20,975.33 for swallowed topical steroids. While the six-food elimination diet was the dominant strategy, PPIs cost the least on a two-year time horizon and were the dominant initial strategy from a societal perspective on both two- and five-year time horizons, as well as the most cost-effective first-line drugs. Two- and four-food elimination diets were also cost-effective for initial management. Dupilumab would not be cost-effective compared to swallowed topical steroids unless the cost per quarter was reduced from $7,311 to $2,038.50 per price threshold analysis under permissive modeling conditions, the study found.

The researchers noted that their models did not include indirect costs and assumed consistent treatment responses, among other limitations. They concluded that the six-food, four-food, and two-food elimination diets were the most cost-effective EoE treatments from a payer perspective at two and five years and that pharmacologic therapy was preferred when patient-relevant costs were included, with PPIs favored among the first-line drugs, followed by steroids and dupilumab.

The choice of initial therapy for EoE should be a shared decision between clinicians and patients, the researchers said. “Factors that may need to be considered in the clinical setting may include cost, access to treatment, tolerance of therapy, patient preference, and convenience,” they wrote. “While our study indicates that elimination diets may be the most cost-effective initial strategy from the payors' perspective, it may carry significant burden from the patients' standpoint, including the need for frequent endoscopy during food re-introduction, impact on quality of life on a more restrictive diet, and the long-term cost of the diet.”