A health economic analysis of noninjectable epinephrine compared with intramuscular epinephrine

Marcus S Shaker; John Oppenheimer; Nicholas L Rider; David B K Golden; Aikaterini Anagnostou; Matthew Greenhawt

doi:10.1016/j.anai.2024.11.025

A health economic analysis of noninjectable epinephrine compared with intramuscular epinephrine

Ann Allergy Asthma Immunol. 2024 Dec 3:S1081-1206(24)01715-0. doi: 10.1016/j.anai.2024.11.025. Online ahead of print.

Authors

Marcus S Shaker¹, John Oppenheimer², Nicholas L Rider³, David B K Golden⁴, Aikaterini Anagnostou⁵, Matthew Greenhawt⁶

Affiliations

¹ Section of Allergy and Clinical Immunology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Departments of Medicine and Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Electronic address: [email protected].
² Department of Internal Medicine, University of Medicine and Dentistry of New Jersey - Rutgers New Jersey Medical School, Newark, New Jersey.
³ The Carillion Clinic, Section of Allergy and Immunology, Department of Health Systems & Implementation Science, Virginia Tech Carilion School of Medicine, Roanoke, Virginia.
⁴ Division of Allergy-Clinical Immunology, Johns Hopkins School of Medicine, Baltimore, Maryland.
⁵ Division of Allergy and Immunology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
⁶ Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.

PMID: 39637974
DOI: 10.1016/j.anai.2024.11.025

Abstract

Background: Noninjectable epinephrine to treat allergic reactions addresses an unmet need. Intranasal epinephrine is approved and a sublingual form is under development. Inhaled epinephrine is poorly studied for anaphylaxis. These forms have unknown cost-effectiveness.

Objective: To evaluate cost-effectiveness of commercially available noninjectable epinephrine compared with intramuscular epinephrine for treatment of anaphylaxis.

Methods: Markov cohort analyses evaluated the cost-effectiveness of noninjectable epinephrine forms. The base-case assumed exaggerated anaphylaxis fatality rates (50-fold increase) for using inhaled epinephrine given low certainty evidence in anaphylaxis and deliberately reduced fatality risk for nasal or sublingual forms (10-fold reduction) theorizing higher adherence and early use during an allergic reaction.

Results: In the base-case scenario, assuming a 10-fold decreased risk in peanut allergy fatality associated with intranasal or sublingual epinephrine treatment for a severe allergic reaction (net monetary benefit [NMB], $2,189,134) vs intramuscular epinephrine use (NMB, $2,189,114), intranasal or sublingual epinephrine was the most cost-effective option (incremental cost-effectiveness ratio [ICER], $83,748/quality-adjusted life-year [QALY]), but only at a marginal annual cost of $4. Intramuscular epinephrine was cost-effective (ICER, $17,900/QALY) vs inhaled epinephrine (NMB, $2,183,531), although inhaled epinephrine reached cost-effectiveness (willingness to pay [$100,000/QALY]) if associated fatality risk fell below 2.5-fold. Substituting a single noninjectable form of epinephrine for a second injectable device (in patients prescribed 2 autoinjectors already) would be cost-effective; however, adding a supplemental noninjectable device was not cost-effective, even assuming a 10-fold risk reduction with multiple device carriage (ICER, $858,462).

Conclusion: Noninjectable routes of epinephrine can be cost-effective options provided fatality risk is not significantly elevated. Carriage of redundant epinephrine autoinjectors with noninjectable forms is not cost-effective if associated with excess cost of redundant device packs.