OBJECTIVES

For pediatric patients deemed ultra-rapid metabolizers (UMs), genetic variability in CYP2D6 increases codeine’s risk of respiratory depression and death. As the cost of pharmacogenomics (PGx) testing decreases and the sensitivity and specificity of PGx testing improves, pain management may benefit from greater PGx-testing adoption. The objective of this study is to determine the cost-effectiveness of PGx testing to guide short-term post-surgical codeine therapy in pediatric patients.

METHODS

We developed a TreeAge-based decision analytical model to compare opioid analgesia with and without PGx testing using a payer’s perspective. For PGx-guided opioid analgesia, we restricted the use of codeine to non-UMs only and considered alternative opioids among patients deemed UMs. We measured the effectiveness as (i) reduction in the hospital length of stay (LOS) due to opioid-induced adverse drug reactions (ADRs) related to the respiratory system, and (ii) averting respiratory depression, a severe opioid-induced ADR. Model parameters were taken from published literature.

RESULTS

Compared to non-PGx testing, PGx testing resulted in approximately 0.0441 fewer LOS days with an incremental cost of $362, resulting in TreeAge reported incremental cost-effectiveness ratio (ICER) of $8,214. PGx testing also resulted in approximately 0.0055 fewer respiratory depression events with an incremental cost of $404 compared to non-PGx testing. The TreeAge reported ICER value was estimated at $73,177 to avert a severe respiratory depression event with PGx testing. The results were robust in probabilistic sensitivity analyses for LOS outcomes. However, for the respiratory depression outcome, 71.8% of iterations resulted in an ICER value exceeding the common $50,000 willingness to pay threshold.

CONCLUSIONS

This analysis suggested that PGx guided opioid analgesia with codeine is a cost-effective strategy for pain management in pediatric patients. As the availability and cost of PGx testing improve, policymakers may want to reconsider the benefit of PGx guided pain management, including codeine.