The cost-effectiveness of abobotulinumtoxinA (Dysport) and onabotulinumtoxinA (Botox) for managing spasticity of the upper and lower limbs, and cervical dystonia

Figures & data

Figure 1. Schematic model structure. Abbreviations: QALY, quality-adjusted life-year; QoL, quality of life.

Table 1. Model inputs for each population.

	AUL: GAS	ALL: MAS	PLL: MAS	CD: TWSTRS
Base case response rates (N)
aboBoNT-A	75.5% (555)^26	35.8% (567)^27	53.8% (156)^13	32.0% (253)^53
onaBoNT-A	60.2% (196)^26	17.2% (588)^27	38.5% (153)^13	22.3% (103)^53
Base case utility values (standard error)
	AUL: DAS	ALL: WV	PLL: WV	CD: TWSTRS
Responder	0.63 (0.01)^36	0.54 (0.01)^38	0.54 (0.01)^38	0.76 (0.03)^41
Non-responder	0.50(0.01)^36	0.49 (0.01)^38	0.49 (0.01)^38	0.60 (0.03)^41
Treatment doses
	AUL (mean; SD, n)^18	ALL (label-based dose)^a	PLL (label-based dose)^a	CD (median, n)^25
aboBoNT-A	843 U (353 U, n = 555)	1,500 U	15 U/kg/side	500 U (n = 279)
onaBoNT-A	256 U (136 U, n = 198)	400 U	6 U/kg/side	160 U (n = 113)
Number of weeks between treatment doses
	AUL^11	ALL^b	PLL^b	CD^b
aboBoNT-A	32	12	12	12
onaBoNT-A	29

Abbreviations: AboBoNT-A, abobotulinumtoxinA; ALL, adult lower limb; AUL, adult upper limb; CD, cervical dystonia; DAS, Disability Assessment Scale; MAS, Modified Ashworth Scale; GAS, Goal Attainment Scale; onaBoNT-A, onabotulinumtoxinA; PGA, Physician’s General Assessment; PLL, pediatric lower limb; TWSTRS, Toronto Western Spasmodic Torticollis Rating Scale; WV, Walking velocity.

^aRecommended doses based on label prescribing information for Botox (aboBoNT-A)⁹ and Dysport (onaBoNT-A)⁸.

^bAssumption based on minimum dosing interval by label.

Table 2. List price for aboBoNT-A and onaBoNT-A.

	Vial size (U)	Cost per vial	Source
aboBoNT-A	300	£93	British National Formulary^33
	500	£154	British National Formulary^33
onaBoNT-A	50	£78	British National Formulary^33
	100	£138	British National Formulary^33
	200	£276	British National Formulary^33

Abbreviations: AboBoNT-A, abobotulinumtoxinA; onaBoNT-A, onabotulinumtoxinA; U, units.

Table 3. Base case deterministic results.

	AUL		ALL		PLL		CD
	onaBoNT-A	aboBoNT-A	onaBoNT-A	aboBoNT-A	onaBoNT-A	aboBoNT-A	onaBoNT-A	aboBoNT-A
Total costs	£34,138	£33,834	£36,089	£35,695	£31,703	£27,740	£4,972	£4,356
Toxin therapy costs	£947	£642	£2,898	£2,505	£7,587	£3,621	£1,276	£808
Healthcare costs	£33,191	£33,191	£33,190	£33,191	£24,117	£24,119	£3,696	£3,548
Total QALYs	0.573	0.595	0.491	0.501	0.418	0.433	0.597	0.616
QALYs based on response status^a	0.579	0.604	0.500	0.509	0.510	0.518	0.636	0.651
AE disutility^b	−0.007	−0.006	−0.009	−0.008	−0.093	−0.085	−0.039	−0.035
ICER	aboBoNT-A dominates		aboBoNT-A dominates		aboBoNT-A dominates		aboBoNT-A dominates
Response rate	60.2%	75.5%	17%	36%	39%	54%	22%	32%
Cost per responder	£56,708	£44,813	£209,817	£99,708	£82,346	£51,562	£22,296	£13,612

Abbreviations: AE, adverse event; ALL, adult lower limb; AUL, adult upper limb; CD, cervical dystonia; ICER, incremental cost effectiveness ratio; PLL, pediatric lower limb; QALY, quality-adjusted life year.

^aQALYs based on response status result from differential utilities by responders vs. non-responders (Table 1) and difference in response rates by treatment (Table 1).

^bQALYs based on adverse events related to use of oral medications by responders vs. non-responders and resultant risk of adverse event and disutility (Supplementary Tables A7–A10) and difference in response rates by treatment (Table 1).

Table 4. Scenario analysis results.

	AUL		ALL		PLL		CD
	onaBoNT-A	aboBoNT-A	onaBoNT-A	aboBoNT-A	onaBoNT-A	aboBoNT-A	onaBoNT-A	aboBoNT-A
No treatment wastage
Total costs	£34,030	£33,805	£36,089	£35,695	£26,045	£25,556	£4,792	£4,356
Total QALYs	0.573	0.595	0.491	0.501	0.418	0.433	0.597	0.616
ICER	aboBoNT-A dominates		aboBoNT-A dominates		aboBoNT-A dominates		aboBoNT-A dominates
Response rate	60.2%	75.5%	17%	36%	39%	54%	22%	32%
Cost per responder	£56,528	£44,775	£209,817	£99,708	£67,648	£47,502	£21,490	£13,612
Non-responders receive one injection
Total costs	£33,972	£33,773	£34,243	£34,458	£28,114	£26,453	£4,285	£3,990
Total QALYs	0.573	0.595	0.491	0.501	0.418	0.433	0.597	0.616
ICER	aboBoNT-A dominates		£21,234		aboBoNT-A dominates		aboBoNT-A dominates
Response rate	60.2%	75.5%	17%	36%	39%	54%	22%	32%
Cost per responder	£56,433	£44,732	£199,085	£96,253	£73,024	£49,170	£19,217	£12,469
Exclude disutility of AEs
Total costs	£34,138	£33,834	£36,089	£35,695	£31,703	£27,740	£4,972	£4,356
Total QALYs	0.579	0.600	0.500	0.509	0.510	0.518	0.636	0.651
ICER	aboBoNT-A dominates		aboBoNT-A dominates		aboBoNT-A dominates		aboBoNT-A dominates
Response rate	60.2%	75.5%	17%	36%	39%	54%	22%	32%
Cost per responder	£56,708	£44,813	£209,817	£99,708	£82,346	£51,562	£22,296	£13,612
Health services cost by response status based on Ward et al.^46 publication (adult indications only)
Total costs	£8,759	£8,299	£11,146	£10,564	NA		NA
Total QALYs	0.573	0.595	0.491	0.501
ICER	aboBoNT-A dominates		aboBoNT-A dominates
Response rate	60.2%	75.5%	17%	36%
Cost per responder	£14,550	£10,993	£64,804	£29,509

Abbreviations: AE, adverse event; ALL, adult lower limb; AUL, adult upper limb; CD, cervical dystonia; ICER, incremental cost effectiveness ratio; PLL, pediatric lower limb; QALY, quality-adjusted life year.

Jacinto J, Ashford S, Fheodoroff K, et al. Factors associated with favorable response in real-world use of botulinum toxin a products for adult patients with upper limb spasticity. TOXINS 2022; July 27–30, 2022, New Orleans, LA.

 Google Scholar

Schnitzler A, Danchenko N, Lundkvist J, et al. PND13 network meta-analysis for botulinum toxin a for the treatment of adult lower limb spasticity (ALLS) in post-stroke population. Value Health. 2020;23:S260.

 PubMed Web of Science ®Google Scholar

Guyot P, Kalyvas C, Mamane C, et al. Botulinum toxins type A (BoNT-A) in the management of lower limb spasticity in children: a systematic literature review and bayesian network Meta-analysis. J Child Neurol. 2019;34(7):371–381.

 PubMed Web of Science ®Google Scholar

Misra VP, Danchenko N, Maisonobe P, et al. Economic evaluation of abobotulinumtoxinA vs onabotulinumtoxinA in real-life clinical management of cervical dystonia. J Clin Mov Disord. 2020;7(2):2–10.

 PubMedGoogle Scholar

Doan QV, Brashear A, Gillard PJ, et al. Relationship between disability and health-related quality of life and caregiver burden in patients with upper limb poststroke spasticity. Pm R. 2012;4(1):4–10.

 PubMedGoogle Scholar

Moore P. Cost-effectiveness analysis on dysport: a focus on early intervention to improve barefoot walking speed. Value Health. 2021;24:S160.

 Web of Science ®Google Scholar

Hilker R, Schischniaschvili M, Ghaemi M, et al. Health related quality of life is improved by botulinum neurotoxin type a in long term treated patients with focal dystonia. J Neurol Neurosurg Psychiatry. 2001;71(2):193–199.

 PubMed Web of Science ®Google Scholar

Turner-Stokes L, Ashforda S, Jacintod J, et al. Economic outcomes in real-world use of botulinum toxin-A products for adult patients with upper limb spasticity: a UK perspective. Paper presented at: TOXINS 2021; January 16–17, 2021.

 Google Scholar

Misra VP, Ehler E, Zakine B, et al. Factors influencing response to botulinum toxin type a in patients with idiopathic cervical dystonia: results from an international observational study. BMJ Open. 2012;2(3):e000881.

 PubMed Web of Science ®Google Scholar

Jacinto J, Ashford S, Fheodoroff K, et al. Real-life data on the time to retreatment with botulinum toxin a in upper limb spasticity management. World Congress for NeuroRehabilitation, 2020; October 7–11 Virtual Congress.

 Google Scholar

Botox powder for solution for injection. 2020. [cited 2020 Oct 12]. https://www.medicines.org.uk/emc/product/859/smpc.

 Google Scholar

Dysport powder for solution for injection. 2020. [cited 2020 Oct 12]. https://www.medicines.org.uk/emc/product/7261/smpc.

 Google Scholar

British National Formulary [Internet]. British Medical Association and Royal Pharmaceutical Society of Great Britain. 2020. [cited 2020 Jan 10]. https://bnf.nice.org.uk/.

 Google Scholar