Liver transplantation is the only effective treatment option for patients with end-stage liver disease. While one-year graft survival rates are over 80% and longer-term graft and patient survival have increased dramatically since the first liver transplants, non-adherence to immunosuppression is still common and confers an increased risk of graft rejection and loss. Prolonged-release tacrolimus (PR-TAC) is a once-daily formulation of tacrolimus that may improve adherence and cause less interference with the daily activities of the patient. The present study evaluated the cost-utility of PR-TAC relative to immediate-release tacrolimus (IR-TAC) and cyclosporine in liver transplant recipients in Canada.

A three-state Markov model was developed to evaluate cost and utility outcomes in adult de novo liver transplant recipients using IR-TAC, PR-TAC, or cyclosporine as the primary immunosuppressive regimen. Costs were derived from Canadian sources and reported in 2016 Canadian dollars, with future costs and effects discounted at 1.5% per annum. Underlying probabilities of mortality were based on a least squares exponential model fit to data from the Canadian Organ Replacement Register, while incremental rates were determined by the results of a network meta-analysis (NMA).

Over a 25-year time horizon, quality-adjusted life expectancy (QALE) increased from 12.22 quality-adjusted life years (QALYs) with IR-TAC to 13.04 QALYs with PR-TAC with an accompanying increase in costs of CAD 38,899, resulting in an incremental cost-effectiveness ratio of CAD 47,351 per QALY gained. Cyclosporine increased costs by CAD 4,478 and reduced QALE by 0.37 QALYs relative to IR-TAC. Sensitivity analysis showed the model to be most sensitive to mortality odds ratios and tacrolimus unit costs.

Cost-utility modeling using modern data from a NMA and Canadian cost data showed that PR-TAC would likely be cost-effective relative to IR-TAC in Canada. Higher per-milligram acquisition costs need not, therefore, present a barrier to its reimbursement.