OBJECTIVES: Onychomycosis is a fungal infection of the nail that accounts for 50% of all nail disease cases. Pharmacological options include oral and topical antifungal agents that could be limited by safety concerns and may be restricted to more severe cases. Consequently, factors such as the severity of nail involvement, side effects, drug-drug interactions, monitoring, diagnostic testing and patient preference influence the treatment selection.The objective of this analysis was to assess the cost-effectiveness of efinaconazole for the treatment of mild to moderate toenail onychomycosis in Canada.

METHODS: A cost-utility analysis was conducted to compare efinaconazole to no treatment for the management of mild to moderate onychomycosis from a healthcare system and societal perspective. A decision tree was developed to capture mycological cures and recurrences associated with efinaconazole or no treatment over a 5-year horizon. The decision tree considered a topical antifungal therapy (efinaconazole) or no treatment as first-line treatment, while a systemic antifungal therapy (terbinafine or itraconazole) was considered as second-line treatment option. Efficacy outcomes were obtained from the two pivotal trials by Elewski et al., from the network meta-analysis conducted by Gupta et al.and from the long-term follow-up study by Piraccini et al.Utility data were retrieved from the literature. Costs were obtained from provincial formularies, manufacturer and literature.

RESULTS: Efinaconazole compared to no treatment was associated with a QALY gain of 0.0027 and incremental costs of C$108.13 and C$20.94 from a healthcare system and a societal perspective, respectively. Therefore, the incremental cost-utility ratio of efinaconazole compared to no treatmentwas C$40,751/QALY and C$7,892/QALY from a healthcare system and from a societal perspective, respectively.

CONCLUSIONS: Efinaconazole is a cost-effective option for the treatment of mild to moderate toenail onychomycosis in Canada, providing a valuable alternative to systemic agents that are limited by safety concerns and drug interactions.