What's the Right Value-Based Cost for Epinephrine Injectors for Peanut Allergy?

Marcus Shaker, MD, MS

Value-based drug pricing is all about centering the cost of a drug around the degree of benefit it provides to society and the patients who use it. So what is the maximum price tag that medicine can hang on self-injectable epinephrine autoinjectors for children with peanut allergy before their financial costs begin to thwart their ability to save lives?

According to a new cost-effectiveness analysis from investigators at the Dartmouth Geisel School of Medicine, the answer is a cool $24.

“Current autoinjector prices are not cost-effective in preventing an outcome of fatality from food allergy,” wrote study authors, led by Marcus Shaker, MD, MS. “However, at a price of $24 per year, personal epinephrine prescriptions become cost-effective. Access and fair pricing of potentially life-saving medication has been a continuing concern as technological breakthroughs deliver new innovations to autoinjector design. Incorporating value-based pricing into epinephrine market price decisions has the ability to add reasonable and rational benchmarks to a controversy that continues to baffle patients, practitioners and payers.”

To arrive at their conclusions, investigators compared simulated birth cohorts of children with peanut allergy, with and without personal epinephrine autoinjector prescriptions (N = 100,000 per group), using computer-based mathematical microsimulations over an 80-year time period. Markov models were used to facilitate incorporation of annual costs and ongoing risks of peanut exposures and reactions, as well as incremental risks of fatal food allergic reactions.

In these simulations, all children who received epinephrine or experienced anaphylaxis as a result of an allergic reaction to peanut were evaluated and treated in an emergency department. All-cause age-adjusted mortality was applied to each cohort using 2013 US Life Tables. Food allergy fatality rates were based on a previous systematic review and meta-analysis.

The simulations compared patients who received annual individual prescriptions for self-injectable epinephrine with those did not. Outcomes measured were costs, quality-adjusted life-years (QALYs), and risk-specific fatalities.

Investigators found that the cost of anaphylaxis preparedness and treatment was higher in patients receiving annual prescriptions for personal epinephrine autoinjector twin packs ($25,478 [95% CI, $25,399-$25,557]) compared with those who did not receive annual prescriptions ($654 [95% CI, $645-$663]).

Assuming a 10-fold risk increase from not maintaining a personal epinephrine autoinjector led to a small difference in the mean number of QALYs per patient (27.4446 vs 27.4335). The average rate of food allergy fatality was 0.00056 (95% CI) per patient prescribed self-injectable epinephrine and 0.00148 (95% CI) in those not prescribed a personal autoinjector twin pack.

At a cost-effectiveness ceiling of $100,000 per QALY, an annual prescription personal epinephrine auto-injector priced at $175 was not cost-effective. However, at a cost of $24 per personal autoinjector epinephrine twin pack device prescription, the ICER for annual prescription was $99,796 QALY.

“As anaphylaxis awareness has increased, the price of the devices has risen sharply in the past 6 to 7 years without much explanation,” the authors wrote. “This culminated in a pricing crisis in 2016, when AUVI-Q was voluntarily taken off the market and EpiPen prices surged to their current levels of more than $600 per twin pack in the absence of its closest competitor…Epinephrine is the unequivocal drug of choice for anaphylaxis and other severe allergic reactions. However, the drug has to be affordable so that patients are neither priced out of epinephrine access nor forced to make other compromises to obtain an autoinjecting form of a drug that costs approximately $1.”

The study, Association of Fatality Risk With Value-Based Drug Pricing of Epinephrine Autoinjectors for Children with Peanut Allergy was published in the Journal of the American Medical Association.