Cost Efficiency of Esketamine Nasal Spray Versus Quetiapine for Treatment Resistant Depression

Objective To compare the per-patient direct and indirect costs associated with achieving remission with esketamine nasal spray plus oral antidepressants (ESK NS+OAD) versus quetiapine extended release plus oral antidepressants (QTP XR+OAD) among patients with treatment-resistant depression (TRD). This comparison was based on a subanalysis of results from the ESCAPE-TRD Phase 3b trial (ex-US) comparing response and remission rates for ESK NS+OAD vs QTP XR+OAD in TRD patients over 32 weeks. Methods An Excel-based model was developed to estimate the cost-per-remitter for ESK NS+OAD and QTP XR+OAD from the perspective of a commercial insurance plan in the US. Remission rates, response rates, and relapse rates (among patients remitting or responding during the first 8 weeks of treatment) were estimated in 4-week intervals over 32 weeks using data from the ESCAPE-TRD Phase 3b clinical trial comparing ESK NS+OAD versus QTP XR+OAD in patients with TRD. Patients not remitting/responding (non-responders) or experiencing a relapse either stayed on current treatment (i.e., ESK NS+OAD or QTP XR+OAD) or discontinued current treatment and initiated either augmented therapy with antipsychotics (APS) or recurring transcranial magnetic stimulation (rTMS). For basecase analysis, equal proportions of non-responders off-treatment initiated rTMS or augmented therapy with APS. In a scenario analysis, all non-responders off-treatment initiated rTMS. Direct costs, including medical and drug costs, were derived from health economic literature and the RED BOOK® drug pricing database. Indirect costs attributed to work productivity loss from presenteeism and absenteeism were derived from a separate analysis of ESCAPE-TRD patients using the Work Productivity and Activity Impairment: Depression (WPAI:D) questionnaire and US Bureau of Labor Statistics survey results. Results The cumulative relapse-free remission rate at 32 weeks was 50% for patients receiving ESK NS+OAD and 33% for patients receiving QTP XR+OAD. In the basecase analysis, the cost-per-remitter (including direct and indirect costs) for ESK NS+OAD was $3,102.17 lower than that of QTP XR+OAD. In the scenario where 100% of non-responders off-treatment were assumed to initiate rTMS, the cost-per-remitter (including direct and indirect costs) for ESK NS+OAD was $15,133.66 lower than that of QTP XR+OAD. Conclusion These findings suggest that esketamine nasal spray in conjunction with oral antidepressants is a cost-efficient alternative compared with quetiapine extended release for treatment of TRD for commercial insurance plans. The comparative benefits associated with ESK NS+OAD treatment are driven primarily by better short- and long-term efficacy observed in the trial and particularly pronounced when considering the costs associated with lost productivity. Funding Janssen Scientific Affairs, LLC