| dc.description.abstract | Terminal chronic kidney disease can be treated with hemodialysis (HD), peritoneal dialysis (PD) or by means of renal transplantation. Among these three treatment modalities, the transplant is, according to the literature, the modality that offers better quality of life. Adding to this the progress of the immunosuppressants used in post-transplant, the number of surgeries has increased over time. However, public health system expendures with these innovations has proportionally increased. Post-transplant treatment usually requires the use of a three drugs combination as the immunosuppressive strategy. This strategy consists of one steroid and two immunosuppressants that may be the calcineurin inhibitors - cyclosporin and tacrolimus, or antimetabolites agents azathioprine, mycophenolate mofetil, and also an inhibitor of rapamycin sirolimus and everolimus, immunosuppressives last released in the market. The logic of incorporation of new drugs, coupled with higher costs in a finite health resources scenario, has been the subject of discussion within the Ministry of Health. In this context, the proposal of this study was to develop a cost-effectiveness analysis of rapamycin inhibitors for the maintenance treatment of renal transplantation. We carried out a systematic review and a meta-analysis, in collaboration with the Cochrane Renal Group, in order to assess the effectiveness of Sirolimus (SRL) and everolimus (EVL). We also studied the cost of all immunosuppressive drugs and the cost-effectiveness using the Markov model in Tree Age Pro® software. For this last assessment, SRL or EVL schemes were compared with the follow two schemes: cyclosporine, mycophenolate mofetil, prednisone, and tacrolimus, mycophenolate mofetil, and prednisone. These are, respectively, the main immunosuppressive strategy used in Brazil and the most indicated by large transplant centers in the world. The results of the meta-analysis showed that both the SRL and EVL do not have superior efficacy or safety comparing to other immunosuppressive drugs. SRL and EVL are the only drugs which have patent, and probably because of this, in the cost analysis the milligram average price is higher in every perspective evaluated. As a result of this the strategies that used this kind of drugs also had high costs. Finally, the results of economic model confirmed and complemented previous results and showed that the most cost-effective strategy for the maintenance treatment of kidney transplantation in Brazil was that composed by cyclosporin, mycophenolate mofetil and prednisone. It is important to emphasize that both systematic review and Markov model present limitations, for example, they do not allow for conversion treatment. However, for the originally aim of this project, this work was able to gather all available evidence in relation to the rapamycin inhibitors and showed the need to adjust clinical protocols and therapeutic guidelines for clinical practice to contribute to the integral social role of Unified Health System | |
