Gastroprotective strategies in chronic NSAID users: a cost-effectiveness analysis comparing single-tablet formulations with individual components

Cost-Utility and Budget Impact Analysis for Stopping the Inappropriate Use of Proton Pump Inhibitors After Cessation of NSAID or Low-Dose Acetylsalicylic Acid Treatment

BACKGROUND

In accordance with current guidelines, proton pump inhibitors (PPIs) are now generally prescribed as a protective co-medication in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or low-dose acetylsalicylic acid (LDASA). However, less attention is paid to the corresponding discontinuation of a PPI after cessation of NSAID or LDASA treatment.

OBJECTIVE

The aim of this study was to assess the extent of inappropriate PPI use, as the proportion of patients who started a PPI as a protective co-medication but continued using these drugs after cessation of NSAID and LDASA treatment. We also sought to estimate the potential cost savings and effect gains of discontinuing inappropriate PPI use and the resulting decrease in adverse effects and their detrimental consequences.

METHODS

Pharmacy dispensing data were used to map inappropriate PPI use in 2014 for community-dwelling patients. Strategies with or without PPI continuation were compared in the cost-utility analysis for a time horizon of 5 years from a healthcare perspective. Subsequently, incremental costs and effects (quality-adjusted life-years) were estimated with a Markov model.

RESULTS

Related to NSAID and LDASA treatment, 11.0% and 5%, respectively, of the PPI users were found to inappropriately continue PPI co-treatment. Discontinuation in 71- to 80-year-old patients suggested cost savings of €170.46 (95% confidence interval 75-282) at a 0.003 (95% confidence interval 0.001-0.005) quality-adjusted life-year increase. The total budget impact of stopping inappropriate PPI use related to NSAID/LDASA treatment in the Netherlands would amount to almost €1,050,000 after 1 year. Correspondingly, successful interventions to stop a patient's inappropriate use would cost up to €29 and probably would pay for themselves in the following years.

CONCLUSIONS

A substantial number of patients inappropriately continue to use a PPI after cessation of NSAID or LDASA treatment. Because adverse effects and their detrimental consequences are avoided, interventions to stop inappropriate PPI use, particularly in older patients, are likely to pay for themselves.

Cost-effective Analysis of Proton Pump Inhibitors in Long-term Management of Gastroesophageal Reflux Disease: A Narrative Review

Background: Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder that results from regurgitation of acid from the stomach into the esophagus. Treatment available for GERD includes lifestyle changes, antacids, histamine-2 receptor antagonists (H₂RAs), proton pump inhibitors (PPIs), and anti-reflux surgery. Aim: The aim of this review is to assess the cost-effectiveness of the use of PPIs in the long-term management of patients with GERD. Method: We searched in PubMed to identify related original articles with close consideration based on inclusion and exclusion criteria to choose the best studies for this narrative review. The first section compares the cost-effectiveness of PPIs with H₂RAs in long-term heartburn management. The other sections shall only discuss the cost-effectiveness of PPIs in 5 different strategies, namely, continuous (step-up, step-down, and maintenance), on-demand, and intermittent therapies. Results: Of 55 articles published, 10 studies published from 2000 to 2015 were included. Overall, PPIs are more effective in relieving heartburn in comparison with ranitidine. The use of PPIs in managing heartburn in long-term consumption of nonsteroidal anti-inflammatory drug (NSAID) has higher cost compared with H₂RA. However, if the decision-maker is willing to pay more than US$174 788.60 per extra quality-adjusted life year (QALY), then the optimal strategy is traditional NSAID (tNSAID) and PPIs. The probability of being cost-effective was also highest for NSAID and PPI co-therapy users. On-demand PPI treatment strategy showed dominant with an incremental cost-effectiveness ratio of US$2197 per QALY gained and was most effective and cost saving compared with all the other treatments. The average cost-effectiveness ratio was lower for rabeprazole therapy than for ranitidine therapy. Conclusion: Our review revealed that long-term treatment with PPIs is effective but costly. To achieve long-term cost-effective approach, we recommend on-demand approach to treat heartburn symptoms, but if the symptoms persist, treatment with continuous step-down therapy should be applied.

Cost Effectiveness of Gastroprotection with Proton Pump Inhibitors in Older Low-Dose Acetylsalicylic Acid Users in the Netherlands

Purpose

The present study aimed to assess the cost effectiveness of concomitant proton pump inhibitor (PPI) treatment in low-dose acetylsalicylic acid (LDASA) users at risk of upper gastrointestinal (UGI) adverse effects as compared with no PPI co-medication with attention to the age-dependent influence of PPI-induced adverse effects.

Methods

We used a Markov model to compare the strategy of PPI co-medication with no PPI co-medication in older LDASA users at risk of UGI adverse effects. As PPIs reduce the risk of UGI bleeding and dyspepsia, these risk factors were modelled together with PPI adverse effects for LDASA users 60–69, 70–79 (base case) and 80 years and older. Incremental cost-utility ratios (ICURs) were calculated as cost per quality-adjusted life-year (QALY) gained per age category. Furthermore, a budget impact analysis assessed the expected changes in expenditure of the Dutch healthcare system following the adoption of PPI co-treatment in all LDASA users potentially at risk of UGI adverse effects.

Results

PPI co-treatment of 70- to 79-year-old LDASA users, as compared with no PPI, resulted in incremental costs of €100.51 at incremental effects of 0.007 QALYs with an ICUR of €14,671/QALY. ICURs for 60- to 69-year-old LDASA users were €13,264/QALY and €64,121/QALY for patients 80 years and older. Initiation of PPI co-treatment for all Dutch LDASA users of 60 years and older at risk of UGI adverse effects but not prescribed a PPI (19%) would have cost €1,280,478 in the first year (year 2013 values).

Conclusions

PPI co-medication in LDASA users at risk of UGI adverse effects is generally cost effective. However, this strategy becomes less cost effective with higher age, particularly in patients aged 80 years and older, mainly due to the increased risks of PPI-induced adverse effects.

A reference case for economic evaluations in osteoarthritis: an expert consensus article from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)

BACKGROUND

General recommendations for a reference case for economic studies in rheumatic diseases were published in 2002 in an initiative to improve the comparability of cost-effectiveness studies in the field. Since then, economic evaluations in osteoarthritis (OA) continue to show considerable heterogeneity in methodological approach.

OBJECTIVES

To develop a reference case specific for economic studies in OA, including the standard optimal care, with which to judge new pharmacologic and non-pharmacologic interventions.

METHODS

Four subgroups of an ESCEO expert working group on economic assessments (13 experts representing diverse aspects of clinical research and/or economic evaluations) were charged with producing lists of recommendations that would potentially improve the comparability of economic analyses in OA: outcome measures, comparators, costs and methodology. These proposals were discussed and refined during a face-to-face meeting in 2013. They are presented here in the format of the recommendations of the recently published Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement, so that an initiative on economic analysis methodology might be consolidated with an initiative on reporting standards.

RESULTS

Overall, three distinct reference cases are proposed, one for each hand, knee and hip OA; with diagnostic variations in the first two, giving rise to different treatment options: interphalangeal or thumb-based disease for hand OA and the presence or absence of joint malalignment for knee OA. A set of management strategies is proposed, which should be further evaluated to help establish a consensus on the "standard optimal care" in each proposed reference case. The recommendations on outcome measures, cost itemisation and methodological approaches are also provided.

CONCLUSIONS

The ESCEO group proposes a set of disease-specific recommendations on the conduct and reporting of economic evaluations in OA that could help the standardisation and comparability of studies that evaluate therapeutic strategies of OA in terms of costs and effectiveness.