Cost-effectiveness of hetrombopag, eltrombopag, and avatrombopag for chronic immune thrombocytopenia in China: a cost-utility analysis

Objectives: Thrombopoietin receptor agonists (TPO-RAs) are standard second-line therapies for chronic immune thrombocytopenia (ITP). Given the introduction of domestic options like hetrombopag, a comparative economic evaluation is essential to inform reimbursement policies in China. This study assessed the cost-effectiveness of hetrombopag, eltrombopag, and avatrombopag for Chinese adults with chronic ITP. Methods: A hybrid model comprising a decision tree and a Markov process was developed to simulate lifetime costs and health outcomes from the perspective of the Chinese healthcare system. Clinical efficacy parameters were derived from randomized controlled trials and a network meta-analysis (NMA). Utilities and costs were estimated using published literature and local data, respectively. Future costs and quality-adjusted life-years (QALYs) were discounted at 5% annually. The primary outcome was the incremental net monetary benefit (iNMB) at a willingness-to-pay (WTP) threshold of CNY 287,391/QALY. Deterministic and probabilistic sensitivity analyses were performed to evaluate uncertainty. Results: Over a lifetime horizon, hetrombopag was the lowest-cost strategy (CNY 2,205,717), followed by eltrombopag (CNY 2,214,322) and avatrombopag (CNY 2,379,335). Although avatrombopag yielded the highest QALYs (10.449), hetrombopag (10.335 QALYs) dominated eltrombopag (10.159 QALYs) by providing greater health benefits at lower costs. Compared with avatrombopag, hetrombopag generated a positive iNMB of CNY 140,864, as the substantial cost savings outweighed the marginal reduction in QALYs. Probabilistic sensitivity analysis indicated that hetrombopag had the highest probability of being cost-effective across standard WTP thresholds. Conclusion: Under current pricing, hetrombopag represents the most cost-effective second-line TPO-RA for adult chronic ITP in China. It dominates eltrombopag and offers a favorable economic profile compared with avatrombopag. These findings support the use of hetrombopag as a preferred option in resource-limited settings.