OBJECTIVES: This study aims to assess the cost-utility of Botulinum toxin type A (BoNT-A) for the treatment of upper limb (UL) and lower limb (LL) post-stroke spasticity (PS).

METHODS: A Markov model with a 3-month cycle length were constructed using a societal perspective to evaluate costs and health outcomes over a lifetime horizon, with a 3% annual discount rate. Abobotulinum toxin A (Abo), Onabotulinum toxin A (Ona), or Prabobotulinum toxin A (Pra), in combination with standard of care (SoC), were compared to SoC alone. Direct medical costs were estimated using a generalized linear model based on five-year retrospective treatment costs from a tertiary hospital. Data on direct non-medical costs, utility, and transitional probabilities were primarily obtained from three tertiary hospitals. Treatment efficacy was determined through a network meta-analysis. Lifetime cost, quality-adjusted life years (QALY) and incremental cost-effectiveness ratio (ICER) were calculated and compared to a cost-effectiveness threshold of 160,000 THB (US $4,597, where 1 USD = 34.81 THB in 2023) per QALY gained. One-way and probabilistic sensitivity analyses were conducted to assess the uncertainty of model input parameters.

RESULTS: The combination of Abo and SoC yielded the highest QALYs gained for UL and LL spasticity (0.013 and 0.008), followed by Ona (0.010 and 0.006) and Pra (0.008 in UL), respectively. Ona incurred the highest additional costs for UL and LL treatment (2,683 THB and 3,407 THB), followed by Abo and Pra. The ICERs for UL treatment with Abo, Ona, and Pra ranged from 167,211 to 270,079 THB per QALY. For LL treatment, Abo and Ona had ICERs ranging from 253,274 to 543,746 THB per QALY. The results were sensitive to the responder’s utility.

CONCLUSIONS: BoNT-A effectively reduces focal spasticity and improves quality of life in PS patients. However, its cost-effectiveness in Thailand necessitates price negotiations for inclusion in the pharmaceutical reimbursement list.