Virtual ACC: Low-dose colchicine after myocardial infarction is “economically dominant”

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During the first Featured Clinical Research session of the virtual American College of Cardiology (ACC) event (28–30 March, Central Time), Michelle Samuel (Montreal Health Institute, Montreal, Canada) reported that the addition of low-dose colchicine (0.5mg daily) to standard-of-care therapy in patients who had a myocardial infarction reduced per patient costs by 69% over a lifetime period. This finding meant that the colchicine incremental cost-effectiveness ratio (ICER) was economically dominant.

Samuel explained that the COLCOT trial, which was presented at the American Heart Association (AHA) meeting last year and simultaneously published in the New England Journal of Medicine, showed that the addition of low-dose colchicine, compared with placebo, was associated a significant 23% reduction in a primary composite endpoint—of death from cardiovascular causes,  resuscitated cardiac arrest, myocardial infarction, stroke, and urgent hospitalisation for angina leading to revascularisation—in patients who had a myocardial infarction. She added that colchicine was a “well-established” anti-inflammatory medication that was “commonly used for gout”.

Given the effectiveness of colchicine observed in the COLCOT trial and that it was already an inexpensive drug (26 cents per pill in Canada), the objective of the current study was to evaluate the cost-effectiveness of colchicine compared with placebo in post myocardial infarction patients receiving standard-of-care therapy.

Samuel and colleagues used a multistate Markov model, based on data from the intention-to-treat results of COLCOT (looking at the first and second events), to assess the two-year and 20-year ICERs of using colchicine after myocardial infarction. “For the in-trial two-year period, treatment with colchicine reduced the average cost per patient by CAD$237—a 47% reduction in cost—and increased quality-adjusted life years (QALYs) by 0.04. The reduction in cost and increase in QALY resulted in a dominant ICER,” Samuel commented. She added that dominance was maintained with the inclusion of all recurrent events and all coronary revascularisation.

Colchicine was also associated with reduced per patient costs of CAD$5,647—a 69% reduction in cost compared with placebo—and an average QALY gain of 2.86 over a 20-year period (lifetime). This again meant that colchicine was an economically dominant strategy (dominant ICER).

Samuel et al also looked at what impact having a higher cost per pill would have on the cost-effectiveness of colchicine. They also presented the two-year and 20-year costs in USA, where colchicine costs about US$4 per pill. “From the US Medicare system perspective, low-dose colchicine therapy post myocardial infarction was cost effective (<$50,000 per QALY) for the in-trial period [two years] and economically dominant at a price of <$5 per pill. From the US private insurance system perspective, low-dose colchicine post myocardial infarction was economically dominant at ≤$5 per pill for the in-trial period and $4–6 per pill for the lifetime period [20 years].”

Panellist Paul Ridker (Center for Cardiovascular Disease Prevention, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA), speaking via video, said: “We talk a lot [in the cardiology community] about drugs that are effective and that we can afford. These data are exceptional in that regard. I am not cost-effective expert but I do know that ‘dominance’ means you save money and I think that is the message you are getting here!”


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