OBJECTIVES

To understand the cost-effectiveness of atovaquone-proguanil (AP) versus artemether-lumefantrine (AL) for the treatment of uncomplicated malaria in the United States, a non-endemic country.

METHODS

A cost-utility analysis was conducted to compare treatment with atovaquone-proguanil versus artemether-lumefantrine, with possible risks of adverse events and no response to treatment. We designed a decision tree model simulation to evaluate the relative cost-effectiveness of our two treatment strategies. The sample population represented Americans who traveled to chloroquine-resistant endemic countries and returned to the United States with a diagnosis of uncomplicated malaria from P. falciparum species. Input parameters were obtained from reported outcomes previously published in comparative effectiveness studies, preference-mapping studies, and randomized control trials. The main outcomes of interest were incremental costs, incremental quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). A one-way sensitivity analysis was performed on all relevant parameters.

RESULTS

The base-case scenario showed that initiating therapy with atovaquone-proguanil versus artemether-lumefantrine resulted in an ICER of -$487.67 per QALY. As such, atovaquone-proguanil was less costly and more effective compared to artemether-lumefantrine; and thus, was the dominant strategy. Results from the sensitivity analysis suggested that the probability of experiencing no adverse events from atovaquone-proguanil was the main driver of the model.

CONCLUSIONS

The analysis revealed that starting treatment with atovaquone-proguanil in non-endemic countries, such as the United States, was a dominant strategy compared to initiating treatment with artemether-lumefantrine in uncomplicated malaria patients. Although it is not cost-effective to initiate treatment with artemether-lumefantrine, its use could be considered as a second-line option in patients who do not respond to or cannot tolerate the side effects of atovaquone-proguanil. Due to the rapidly changing drug resistance patterns of malaria, both physicians and travelers must remain informed to avoid the costs and risks of this potentially severe, but easily preventable, infectious disease.