A cost-effectiveness analysis of denosumab for the prevention of skeletal-related events in patients with multiple myeloma in the United States of America

J Med Econ. 2018 May;21(5):525-536. doi: 10.1080/13696998.2018.1445634. Epub 2018 Mar 5.


Objective: A large, pivotal, phase 3 trial in patients with newly diagnosed multiple myeloma (MM) demonstrated that denosumab, compared with zoledronic acid, was non-inferior for the prevention of skeletal-related events (SREs), extended the observed median progression-free survival (PFS) by 10.7 months, and showed significantly less renal toxicity. The cost-effectiveness of denosumab vs zoledronic acid in MM in the US was assessed from societal and payer perspectives.

Methods: The XGEVA Global Economic Model was developed by integrating data from the phase 3 trial comparing the efficacy of denosumab with zoledronic acid for the prevention of SREs in MM. SRE rates were adjusted to reflect the real-world incidence. The model included utility decrements for SREs, administration, serious adverse events (SAEs), and disease progression. Drug, administration, SRE management, SAEs, and anti-MM treatment costs were based on data from published studies. For the societal perspective, the model additionally included SRE-related direct non-medical costs and indirect costs. The net monetary benefit (NMB) was calculated using a willingness-to-pay threshold of US$150,000. One-way deterministic and probabilistic sensitivity analyses were conducted.

Results: From a societal perspective, compared with zoledronic acid, the use of denosumab resulted in an incremental cost of US$26,329 and an incremental quality-adjusted life-year (QALY) of 0.2439, translating into a cost per QALY gained of US$107,939 and a NMB of US$10,259 in favor of denosumab. Results were sensitive to SRE rates and PFS parameters.

Limitations: Costs were estimated from multiple sources, which varied by tumor type, patient population, country, and other parameters. PFS and overall survival were extrapolated beyond the follow-up of the primary analysis using fitted parametric curves.

Conclusion: Denosumab's efficacy in delaying or preventing SREs, potential to improve PFS, and lack of renal toxicity make it a cost-effective option for the prevention of SREs in MM compared with zoledronic acid.

Keywords: Cost-effectiveness; denosumab; multiple myeloma; skeletal-related events; zoledronic acid.

Publication types

  • Clinical Trial, Phase III
  • Randomized Controlled Trial

MeSH terms

  • Bone Density Conservation Agents / administration & dosage*
  • Bone Density Conservation Agents / economics
  • Bone Diseases / etiology*
  • Bone Diseases / prevention & control*
  • Bone Neoplasms / prevention & control
  • Bone Neoplasms / secondary
  • Cost of Illness
  • Cost-Benefit Analysis
  • Denosumab / administration & dosage*
  • Denosumab / adverse effects
  • Denosumab / economics
  • Diphosphonates / administration & dosage*
  • Diphosphonates / adverse effects
  • Diphosphonates / economics
  • Female
  • Health Expenditures / statistics & numerical data
  • Humans
  • Imidazoles / administration & dosage*
  • Imidazoles / adverse effects
  • Imidazoles / economics
  • Male
  • Models, Economic
  • Multiple Myeloma / complications*
  • Quality-Adjusted Life Years
  • Survival Analysis
  • United States
  • Zoledronic Acid


  • Bone Density Conservation Agents
  • Diphosphonates
  • Imidazoles
  • Denosumab
  • Zoledronic Acid