Cost-Utility of Sildenafil for Persistent Pulmonary Hypertension of the Newborn

Patrick D. Evers, Paul J. Critser, Michelle Cash, Melissa Magness, Susan Hoelle, Russel Hirsch

Research output: Contribution to journalArticlepeer-review


Objective While advanced therapies for severe persistent pulmonary hypertension of the newborn (PPHN) such as inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO) are standard treatments in high-income countries, these therapies are often unavailable in resource-limited settings such as middle-income countries. However, there are small clinical trials illustrating the efficacy of sildenafil at reducing mortality in PPHN. This analysis sought to determine the cost-utility of enteral sildenafil for the treatment of severe PPHN. Study Design A Markov-state transition model was constructed for the two clinical approaches to compare costs, clinical outcomes, and quality of life: (1) conventional, (2) sildenafil. The impact of sildenafil was modeled as a relative risk modifier of the conventional strategy's mortality risk. Transitional probabilities, costs, and utility metrics were extracted from the literature. Sensitivity analyses for each model input as well as 100-patient Monte Carlo simulations were used to test the durability of the model conclusion. Results The sildenafil strategy was cost-effective for upper but not lower middle-income countries with an incremental cost-effectiveness ratio of $2,339 per quality-adjusted life year. This conclusion was durable across a wide-range of model assumptions; the sildenafil strategy only failed to meet criteria for cost-effectiveness when sildenafil therapy had a mortality relative risk efficacy of >0.89, if life expectancy in that country is <40 years, or if the lifetime forecasted costs of a survivor's life was quite high. Conclusion Enteral sildenafil is a cost-effective intervention for severe PPHN for upper middle-income countries where ECMO and iNO are not available. Key Points PPHN is a common life-threatening condition in newborns. Sildenafil improves survival of PPHN. Sildenafil is cost-effective for upper-middle income countries.

Original languageEnglish (US)
Pages (from-to)1505-1512
Number of pages8
JournalAmerican journal of perinatology
Issue number14
StatePublished - Dec 1 2021


  • cost-effectiveness
  • global health
  • pediatrics
  • pulmonary hypertension

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Obstetrics and Gynecology


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