A fixed-duration treatment regimen using venetoclax for first-line chronic lymphocytic leukemia (CLL) demonstrates lower long-term healthcare costs compared to continuous Bruton tyrosine kinase inhibitor (BTKi) treatment, according to real-world data. The study, analyzing Medicare claims, reveals significant cost reductions following the completion of the fixed-duration venetoclax regimen. This economic advantage arises primarily from the elimination of ongoing prescription drug expenses.
Cost Comparison of Venetoclax and BTKi Regimens
The study, published in the Journal of Managed Care Specialty Pharmacy, assessed the costs associated with a venetoclax (Venclexta; AbbVie and Genentech)-based regimen compared to continuous BTKi treatment. The analysis of approximately 1700 Medicare patients' data from 2016 to 2021 showed that the venetoclax-based regimen was associated with an approximate $8000 decrease in costs compared with continuous BTKi treatment six months after the fixed-duration period.
Researchers noted that initial concerns about higher costs for venetoclax due to tumor lysis syndrome monitoring and obinutuzumab co-administration were unfounded. "Although venetoclax is often assumed to have higher overall medical costs owing to the need for tumor lysis syndrome monitoring during the ramp-up phase (including metabolic testing and potentially inpatient hospitalization) and concomitant treatment with obinutuzumab for the first 6 months, our study revealed that in the first 12 months after treatment initiation, patients receiving VEN-O and BTKis actually have similar mean cumulative (~$170,000) and mean monthly (~$14,000) all-cause health care costs (despite having a larger comorbidity burden and higher rate of hospitalization prior to initiating treatment)," the researchers explained.
Cost Reduction After Fixed-Duration Treatment
During the initial 12 months (months 0-12), risk-adjusted all-cause costs were similar between the 193 patients receiving venetoclax + obinutuzumab ($13,887) and the 1577 patients receiving a BTKi ($14,492). While CLL-related physician-administered drug costs were higher for the venetoclax-based regimen due to obinutuzumab, this was offset by higher CLL-related pharmacy costs associated with BTKi use.
However, in the subsequent six months (months 13-18), patients who received venetoclax + obinutuzumab experienced a significant 67% drop in all-cause total costs, decreasing to approximately $4462. This reduction was primarily due to the absence of prescription drug costs. In contrast, costs for BTKi treatment only dropped by 10% during the same period, with all-cause total costs remaining at $13,051.
Implications of Ibrutinib Price Negotiation
The study also considered the impact of the Inflation Reduction Act of 2022, which led to a negotiated price reduction for ibrutinib (Imbruvica; Pharmacyclics and Janssen Biotech). The researchers acknowledged that "depending on the price reduction negotiated for ibrutinib, the costs in the first 12 months may be lower for ibrutinib initiators compared with VEN-O users." However, they emphasized that "a long-term economic outlook is required by payers when comparing the cost-effectiveness of these 2 treatments given the long natural history of CLL. A reduced drug price for ibrutinib may not fully address the continuous costs that payers will incur with treat-to-progression BTKis vs the time-limited costs of fixed-duration treatments like venetoclax."
Future Research Directions
The researchers suggest further investigation into the cost-effectiveness of newer BTKi agents, such as acalabrutinib (Calquence; AstraZeneca) and zanubrutinib (Brukinsa; BeiGene USA), which have demonstrated improved safety profiles compared to ibrutinib. In the current study, only 12% of patients received acalabrutinib, and less than 1% received zanubrutinib. The improved safety profiles of these newer agents could also impact related healthcare costs.
