Terapie aggiuntive nello shock settico: un’analisi di costo-efficacia

DOI 10.23753/htafocus2016.03.014

Marco Barbieri, Massimo Girardis


Background: In this preliminary study we aim to compare the cost-effectiveness of different adjunctive therapies with non-conclusive and/or still debated evidence that may be considered in patients with sepsis or septic shock.
Methods: A literature search was conducted to identify randomized controlled trials (RCTs) and meta-analyses including: steroids in septic shock; albumin in fluid resuscitation; standard intravenous immunoglobuling (IVIG) and IgM-enriched immunoglobulins; high volume continuous renal replacement therapy (CRRT) (35-65 ml/kg/h); hemoperfusion with a Polymyxin B-immobilized cartridge (PMX-B); coupled plasma filtration adsorption (CPFA). On the basis of selected studies, we estimated the efficacy of the treatments of interest calculating the Number Needed to Treat (NNT), and its inverse life-saved (LS) for  estimated by the difference in mortality between treatment and control groups. Cost data of the intervention therapies were obtained from a single referral centre. An ICER (incremental cost per life gained) was calculated for each intervention compared with placebo or standard therapy. No attempt was made to compare costs and benefits among the treatment groups of the different studies, given the high heterogeneity among trials and/or meta-analyses.
Results: LS ranged from a maximum of 0.135 for PMX-B to a minimum of 0.005 for high volume CRRT. Costs varied greatly among treatments, with more expensive options (e.g. PMX-B, CPFA, IgM-enriched IVIG) and extremely low cost options (e.g. steroids, crystalloid). The lowest ICERs were for steroids (€ 188/LS) and IgM-enriched IVIG (€ 33,605/LS). All the other options showed ICERs greater than € 40k/LS and up to € 333k/LS.
Conclusions: Our preliminary analysis suggests that only few of the proposed sepsis adjunctive therapies  seem to provide beneficial effects and show an acceptable cost-effectiveness profile.

Key words: sepsis, literature search, meta-analyses, cost-effectiveness, LS