A framework for evaluating the clinical consequences of initial therapy with NSAIDs, NSAIDs plus gastroprotective agents, or celecoxib in the treatment of arthritis

Economic Impact of Pharmacists' Interventions with Nonsteroidal Antiinflammatory Drugs

Objective:

To estimate the economic impact of community pharmacists' interventions following the detection of problems related to nonsteroidal antiinflammatory drugs (NSAIDs), whether in a prescription or self-medication format. The evaluation focused on the gastroduodenal adverse events that could be avoided and the subsequent savings of healthcare resources spent on treating these adverse effects.

Methods:

A previous study conducted during a 12-week period in 924 French community pharmacies provided the number of interventions for drug-related problems concerning NSAIDs. A simulation model was constructed to compare 2 strategies: a systematic pharmacist's intervention and the absence of intervention. The base-case patient was assumed to have been taking an NSAID for 3 months. The model's inputs were extracted from medical literature and from an institutional medical database.

Results:

In this study, 608 interventions were the results of NSAID-related problems. All of these interventions reduced the risk of gastrointestinal adverse events and avoided a total cost of €37 300.

Conclusions:

This model indicates that the dispensing of NSAIDs by pharmacists and related pharmaceutical care activities have a positive impact by reducing the number of gastrointestinal complications. The model quantifies the costs thus avoided. It also underlines the necessity of effective collaboration between the prescriber and the pharmacist if optimal patient management is to be achieved.

Cost-effectiveness analyses of osteoarthritis oral therapies: a systematic review

BACKGROUND

Cost-effectiveness analyses (CEAs) have been performed for oral non-disease-altering osteoarthritis (OA) treatments for well over a decade. During that period the methods for performing these analyses have evolved as pharmacoeconomic methods have advanced, new treatments have been introduced, and the knowledge of associated adverse events (AEs) has improved.

OBJECTIVE

The objective of this systematic review was to trace the development of CEAs for oral non-disease-altering treatments in OA.

METHODS

A systematic search for CEAs of OA oral treatments was performed of the English-language medical literature using the following databases: PubMed, EMBASE, MEDLINE In-Process, EconLit, and Cochrane. Key requirements for inclusion were that the population described patients with OA or arthritis and that the analysis reported at least one incremental cost-effectiveness ratio. Each identified publication was assessed for inclusion. Thirteen characteristics and all AEs appearing in each included CEA were extracted and organized. Reference lists from these CEAs were also searched. A chronology of key CEAs in the field was compiled, noting the characteristics that advanced the state of the art in modeling oral OA treatments.

RESULTS

Thirty publications of 28 CEAs were identified and evaluated. Developments in CEAs included an expanded set of comparators that broadened from non-steroidal anti-inflammatory drugs (NSAIDs) only to NSAIDs plus gastroprotective agents, cyclooxygenase-2 inhibitors, and opioids. In turn, AEs expanded from gastrointestinal (GI) events to also include cardiovascular (CV) and neurological events. Efficacy, which initially was presumed to be equivalent for all treatments, evolved to treatment-specific efficacies. Decision-tree analyses were generally replaced by Markov models or, occasionally, stochastic or discrete event simulation. Finally, outcomes have progressed from GI-centric measures to also include quality-adjusted life-years.

CONCLUSION

Methods used by CEAs of oral non-disease-altering OA treatments have evolved in response to changing treatments with different safety profiles and efficacies as well as technical advances in the application of decision science to health care.

Cost-utility analysis of duloxetine in osteoarthritis: a US private payer perspective

BACKGROUND

Duloxetine has recently been approved in the USA for chronic musculoskeletal pain, including osteoarthritis and chronic low back pain. The cost effectiveness of duloxetine in osteoarthritis has not previously been assessed. Duloxetine is targeted as post first-line (after acetaminophen) treatment of moderate to severe pain.

OBJECTIVE

The objective of this study was to estimate the cost effectiveness of duloxetine in the treatment of osteoarthritis from a US private payer perspective compared with other post first-line oral treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs), and both strong and weak opioids.

METHODS

A cost-utility analysis was performed using a discrete-state, time-dependent semi-Markov model based on the National Institute for Health and Clinical Excellence (NICE) model documented in its 2008 osteoarthritis guidelines. The model was extended for opioids by adding titration, discontinuation and additional adverse events (AEs). A life-long time horizon was adopted to capture the full consequences of NSAID-induced AEs. Fourteen health states comprised the structure of the model: treatment without persistent AE, six during-AE states, six post-AE states and death. Treatment-specific utilities were calculated using the transfer-to-utility method and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores from a meta-analysis of osteoarthritis clinical trials of 12 weeks and longer. Costs for 2011 were estimated using Red Book, The Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project database, the literature and, sparingly, expert opinion. One-way and probabilistic sensitivity analyses were undertaken, as well as subgroup analyses of patients over 65 years old and a population at greater risk of NSAID-related AEs.

RESULTS

In the base case the model estimated naproxen to be the lowest total-cost treatment, tapentadol the highest cost, and duloxetine the most effective after considering AEs. Duloxetine accumulated 0.027 discounted quality-adjusted life-years (QALYs) more than naproxen and 0.013 more than oxycodone. Celecoxib was dominated by naproxen, tramadol was subject to extended dominance, and strong opioids were dominated by duloxetine. The model estimated an incremental cost-effectiveness ratio (ICER) of US$47,678 per QALY for duloxetine versus naproxen. One-way sensitivity analysis identified the probabilities of NSAID-related cardiovascular AEs as the inputs to which the ICER was most sensitive when duloxetine was compared with an NSAID. When compared with a strong opioid, duloxetine dominated the opioid under nearly all sensitivity analysis scenarios. When compared with tramadol, the ICER was most sensitive to the costs of duloxetine and tramadol. In subgroup analysis, the cost per QALY for duloxetine versus naproxen fell to US$24,125 for patients over 65 years and to US$18,472 for a population at high risk of cardiovascular and gastrointestinal AEs.

CONCLUSION

The model estimated that duloxetine was potentially cost effective in the base-case population and more cost effective for subgroups over 65 years or at high risk of NSAID-related AEs. In sensitivity analysis, duloxetine dominated all strong opioids in nearly all scenarios.

[Economic evaluation of tramadol/paracetamol in the management of pain in patients with osteoarthritis in Spain]

OBJECTIVE

To compare the costs of treating osteoarthritis (OA) pain using combination tramadol/paracetamol tablets, Non-Steroidal Anti-Inflammatory Agents (NSAID) alone or NSAID plus proton pump inhibitors (PPI) from the perspective of the Spanish National Health System.

METHODS

A decision-analytical model was constructed to analyze the cost associated with three treatment strategies over 6 months. A cost-minimization approach was used, which considered data related to resource use, medication costs and costs for the treatment of adverse events.

RESULTS

In the base-case analysis, costs for 6 months of treatment of OA pain using tramadol/paracetamol were €232.86, compared with €274.60 for NSAID + PPI and €133.75 for NSAID alone. This provided a savings of €41.74 per patient over 6 months for tramadol/paracetamol compared with NSAID + PPI and a cost increase of €99.11 compared with NSAID alone. When renal adverse events associated with NSAID were considered, tramadol/paracetamol was cost saving compared with all NSAID-based regimens (saving €140.02 vs NSAID alone, €280.86 vs NSAID + PPI).

CONCLUSION

Based on the results of a theoretical decision-analytic model, the data obtained may suggest that tramadol/paracetamol is cost saving compared with NSAID + PPI for the treatment of OA pain over a period of 6 months. Tramadol/paracetamol is also cost saving compared with treatment with NSAID alone if considering renal adverse events.

Are COX-2 inhibitors preferable to combined NSAID and PPI in countries with moderate health service expenditures?

RATIONALE

In developed countries, cyclooxygenase 2 (COX-2) inhibitors were shown to be less costly than the combination of non-steroidal anti-inflammatory drugs (NSAIDs) and proton pump inhibitors (PPIs) in treatment of patients with high risk of serious gastrointestinal (GI) adverse effects. It is questionable if such results apply to developing countries where health service costs are lower and there is high discrepancy between generic and patent protected drug prices. We analysed the direct cost of treatment with generic NSAIDs in combination with PPIs versus branded COX-2 inhibitors in patients with high risk of serious GI adverse effects from the perspective of the public health service in Serbia.

METHODS

Total cost of treatment of serious GI complications and the use of NSAID+PPI versus COX-2 inhibitors were calculated. A model for estimation of cost of treatment of NSAID+PPI versus COX-2 inhibitors which included the probability of developing serious GI adverse effects was developed.

RESULTS

Total cost of treatment of serious GI adverse effects resulted in an average of $814/patient. Considering the relative risk of such adverse effects for patients with four or more risk factors, the least costly treatment over 6 months was the use of celecoxib ($487). Compared with diclofenac+omeprazole, cost savings were estimated at $59 and $22 per patient with celecoxib and etoricoxib, respectively.

CONCLUSION

Cost savings may be achieved by using COX-2 inhibitors in patients at high risk of GI adverse effects even in countries with moderate health care service expenditures. Such possibility requires further investigation.

Nonsteroidal antiinflammatory drug-related injury to the gastrointestinal tract: clinical picture, pathogenesis, and prevention

Increasing life expectancy in developed countries has led to a growing prevalence of arthritic disorders, which has been accompanied by increasing prescriptions for nonsteroidal antiinflammatory drugs (NSAIDs). These are the most widely used agents for musculoskeletal and arthritic conditions. Although NSAIDs are effective, their use is associated with a broad spectrum of adverse reactions in the liver, kidney, cardiovascular system, skin, and gut. Gastrointestinal (GI) side effects are the most common. The dilemma for the physician prescribing NSAIDs is, therefore, to maintain the antiinflammatory and analgesic benefits, while reducing or preventing GI side effects. The challenge is to develop safer NSAIDs by shifting from a focus on GI toxicity to the increasingly more appreciated cardiovascular toxicity.

A comparison of cost effectiveness using data from randomized trials or actual clinical practice: selective cox-2 inhibitors as an example

BACKGROUND

Data on absolute risks of outcomes and patterns of drug use in cost-effectiveness analyses are often based on randomised clinical trials (RCTs). The objective of this study was to evaluate the external validity of published cost-effectiveness studies by comparing the data used in these studies (typically based on RCTs) to observational data from actual clinical practice. Selective Cox-2 inhibitors (coxibs) were used as an example.

METHODS AND FINDINGS

The UK General Practice Research Database (GPRD) was used to estimate the exposure characteristics and individual probabilities of upper gastrointestinal (GI) events during current exposure to nonsteroidal anti-inflammatory drugs (NSAIDs) or coxibs. A basic cost-effectiveness model was developed evaluating two alternative strategies: prescription of a conventional NSAID or coxib. Outcomes included upper GI events as recorded in GPRD and hospitalisation for upper GI events recorded in the national registry of hospitalisations (Hospital Episode Statistics) linked to GPRD. Prescription costs were based on the prescribed number of tables as recorded in GPRD and the 2006 cost data from the British National Formulary. The study population included over 1 million patients prescribed conventional NSAIDs or coxibs. Only a minority of patients used the drugs long-term and daily (34.5% of conventional NSAIDs and 44.2% of coxibs), whereas coxib RCTs required daily use for at least 6-9 months. The mean cost of preventing one upper GI event as recorded in GPRD was US$104k (ranging from US$64k with long-term daily use to US$182k with intermittent use) and US$298k for hospitalizations. The mean costs (for GPRD events) over calendar time were US$58k during 1990-1993 and US$174k during 2002-2005. Using RCT data rather than GPRD data for event probabilities, the mean cost was US$16k with the VIGOR RCT and US$20k with the CLASS RCT.

CONCLUSIONS

The published cost-effectiveness analyses of coxibs lacked external validity, did not represent patients in actual clinical practice, and should not have been used to inform prescribing policies. External validity should be an explicit requirement for cost-effectiveness analyses.

A randomized, multicentre, double-blind, parallel-group study to assess the adverse event-related discontinuation rate with celecoxib and diclofenac in elderly patients with osteoarthritis

OBJECTIVE

To compare the adverse event (AE)-related discontinuation rate with celecoxib vs. diclofenac when given to reduce joint pain associated with knee or hip osteoarthritis (OA) in elderly patients.

METHODS

This was a double-blind, randomized, multicentre, parallel-group, 1-year comparison of celecoxib 200 mg once daily and diclofenac 50 mg twice daily in 925 patients with OA aged > or = 60 years. Study visits were at baseline and at 4, 13, 26, 39, and 52 weeks. At each visit, the Patient's and Physician's Global Assessment of Arthritis (PaGAA, PhGAA), the Patient's Assessment of Arthritis Pain--Visual Analogue Scale (PAAP-VAS), and AEs were assessed. A concomitant health economic analysis was conducted throughout.

RESULTS

The rate of study discontinuation due to AEs, laboratory abnormalities, and deaths was 27% for celecoxib and 31% for diclofenac (p = 0.22). The results of the arthritis/pain efficacy assessments were similar for celecoxib and diclofenac. Significantly fewer patients in the celecoxib group than the diclofenac group experienced cardiovascular/renal AEs (70/458 vs. 95/458, p = 0.039) or hepatic AEs (10/458 vs. 39/458, p<0.0001). Medication costs were higher for celecoxib than diclofenac but mean total treatment cost was slightly higher in the diclofenac group.

CONCLUSION

Treatment with celecoxib 200 mg once daily and diclofenac 50 mg twice daily resulted in similar rates of AE-related study discontinuation in elderly patients with OA. Celecoxib and diclofenac demonstrated comparable efficacy in relieving the signs and symptoms of OA. However, the proportion of patients with cardiorenal and hepatic AEs was significantly lower in the celecoxib group than the diclofenac group.

Myths and facts in the use of anti-inflammatory drugs

BACKGROUND

Because of the prominence of pain-related conditions and the growing complexities of clinical management we aimed to explore and attempt to dispel the several myths that surround these serious therapeutic issues.

AIMS

We aimed to provide a careful analysis of the evidence and draw factually based guidance for physicians who manage the broad range of patients with pain.

METHODS

Current myths were identified based on the authors' clinical, scientific, and academic experience. Each contributor addressed specific topics and made his own selection of primary references and systematic reviews by searching in MEDLINE, EMBASE, and CINAHL databases (1990-2008) as well as in the proceedings of the major digestive and rheumatology meetings. The writing and references provided by each contributor were collectively analyzed and discussed by all authors during several meetings until the final manuscript was prepared and approved.

RESULTS

Seven major 'historical' myths that may perpetuate habits and beliefs in clinical practice were identified. Each of them was thoroughly examined and dispelled, drawing conclusions that should help guide physicians to better manage patients with pain.

CONCLUSIONS

Pain relief must be considered a human right, and patients with osteoarthritis pain should be treated appropriately with analgesic or/and anti-inflammatory drugs. The risk of gastrointestinal (GI) complications with traditional non-steroidal anti-inflammatory drugs (t-NSAIDs) is present from the first dose (with both short-term and long-term use), and strategies to prevent GI complications should be considered regardless of the duration of therapy. Compared with t-NSAIDs, coxib use is associated with a small but significant reduction of dyspepsia. While protecting the stomach, proton pump inhibitors do not prevent NSAID-induced intestinal damage. To this end, coxib therapy could be the preferred option, although further randomized studies are needed. A substantial number of patients who need NSAIDs are also taking low-dose aspirin for cardiovascular prophylaxis. From a GI perspective, the combination of aspirin plus a coxib provides a preferred option compared with aspirin plus a t-NSAID, for patients at high GI risk. As the incidence of renovascular adverse effects with t-NSAIDs and coxibs is similar, blood pressure should be monitored and managed appropriately in patients taking these drugs, although they should be avoided in those with severe congestive heart failure. Due to increased cardiovascular risk, which is dependent on the dose, duration of therapy, and base-line cardiovascular risk, both t-NSAIDs and coxibs should be used with caution in patients with underlying prothrombotic states and/or concomitant cardiovascular risk factors.

Costs and effects of various analgesic treatments for patients with rheumatoid arthritis and osteoarthritis in the Netherlands

OBJECTIVE

To assess the balance between costs and upper gastrointestinal (GI) side effects of treatment with celecoxib, nonsteroidal antiinflammatory drugs (NSAIDs) alone, NSAID plus misoprostol, NSAID plus histamine-2 receptor antagonist (H(2)RA), NSAID plus proton pump inhibitor (PPI), and Arthrotec in The Netherlands.

METHODS

A model was used to convene data from various sources on the probability of GI side effects and resource use. The probabilities of GI side effects for celecoxib and NSAIDs alone were derived from trial data. Calculations were based on 6 months of treatment, and were from a societal perspective. Distinction was made between low-, medium-, and high-risk patients. An extensive probabilistic sensitivity analysis was performed to address uncertainty.

RESULTS

Assuming an average patient, the total costs per 6 months of therapy were: celecoxib 255 Euro, NSAIDs alone 166 Euro, NSAID plus misoprostol 285 Euro, NSAID plus H(2)RA 284 Euro, NSAID plus PPI 243 Euro, and Arthrotec 187 Euro. Treatment with celecoxib was associated with the lowest number of GI side effects and related deaths. Incremental costs per life-year saved for Arthrotec compared to NSAIDs alone were 5676 Euro for all patients and 526 Euro for medium-to-high-risk patients, whereas for high-risk patients, Arthrotec dominated NSAID alone. For celecoxib compared to Arthrotec, the incremental cost-effectiveness ratios (ICERs) were 56,667 Euro, 33,684 Euro, and 15,429 Euro, respectively.

CONCLUSION

Assuming a limit of 20,000 Euro per life-year gained, from an economic point of view, Arthrotec is the preferred treatment when all patients or medium-to-high-risk patients are considered. In high-risk patients, celecoxib is the preferred treatment strategy.

Comorbid Conditions in the AMICA Study Patients: Effects on the Quality of Life and Drug Prescriptions by General Practitioners and Specialists

OBJECTIVE

Osteoarthritis (OA) has been identified as the disease with the highest rate of comorbidities, which may increase the likelihood of disability. The AMICA study evaluated how the presence of a coexistent disease and/or its chronic pharmacological treatment influenced the prescription of pharmacological and nonpharmacological therapy in patients with OA.

PATIENTS AND METHODS

The 2764 general practitioners (GPs) and 316 specialists (98 rheumatologists, 166 orthopedic surgeons, 52 physical medicine specialists) participating in the study were asked to enroll 10 consecutive patients with OA diagnosed according to the American College of Rheumatology clinical criteria. Information was collected regarding demographics, the clinical characteristics of OA, and previous diagnostic and therapeutic interventions. Pain intensity was assessed using a 100-mm visual analog scale (VAS); the patients were also asked to report on their quality of life and joint function, as well as the presence of any concomitant disease and/or therapy. The influence of comorbidities on the quality of life, pain, and drug prescription was evaluated.

RESULTS

A total of 29,132 evaluable patients was observed (25,589 recruited by GPs and 3543 by specialists). The most frequent comorbidities were hypertension (52%), osteoporosis (21%), type II diabetes mellitus (15%), and chronic obstructive pulmonary disease (12%); myocardial infarction and/or angina pectoris were present in 6% and peptic ulcer was present in 5%. Comorbidities were more frequent in older patients and, except in the case of hypertension, were closely related to more intense pain and a decreased quality of life; they were also generally associated with worsened joint function. The presence of peptic ulcer was associated with a reduction in the prescription of nonsteroidal antiinflammatory drugs (NSAIDs) (odds ratio (OR) 0.61; confidence intervals (CI) 0.53 to 0.69) and the more frequent use of Coxibs (OR 1.15; CI 1.03 to 1.28) and simple analgesics (OR 1.42; CI 1.26 to 1.61), as well as with greater use of physical therapy. Hypertension was associated with a reduction in the prescription of physical therapy. NSAIDs and Coxibs were less frequently prescribed if the patients were on anticoagulant therapy (NSAIDs: OR 0.86; CI 0.70 to 1.06; Coxibs: OR 0.77; CI 0.64 to 0.93). Gastroprotective therapy was more frequently used in patients treated with NSAIDs, Coxibs, and analgesics, with GPs giving greater preference to proton pump inhibitors than specialists.

CONCLUSIONS

Comorbidities decrease the quality of life and worsen the joint function in OA patients. Comorbidities and their treatment generally do not influence the physician's choice of OA treatment, with the exception of peptic ulcer and anticoagulant therapy, both of which were associated with a reduction in the prescription of antiinflammatory drugs. There was a preferential use of Coxibs in patients with peptic ulcer, and an underuse of gastroprotective measures in OA patients treated with NSAIDs.

Treatment costs to prevent or treat upper gastrointestinal adverse events associated with NSAIDs

The widespread use of nonselective NSAIDs and cyclo-oxygenase (COX)-2 inhibitors has a substantial impact on healthcare budgets worldwide. The cost of their gastrointestinal (GI) adverse effects is a major component of their direct cost and has received much attention in the literature. Published studies have often differed in their methodologies and results. It is important for decision makers to understand the reasons for these differences in order to make informed decisions. We conducted a literature review to summarise data that evaluate the direct costs of NSAID-related GI adverse effects worldwide. This resulted in 789 articles from which 29 studies met the inclusion criteria and were fully reviewed. Of these 29, the 9 studies that assessed the cost of COX-2 inhibitors were all based on decision economic models, compared with only 7 of the remaining 20 studies, which assessed the cost of nonselective NSAIDs. In most studies, the perspective was that of the healthcare payer and the costs assessed were reimbursement costs. Costs of GI events almost doubled between regular users and non-users of nonselective NSAIDs and were much higher in high-dose versus low-dose users. The ratio of the total cost of nonselective NSAIDs to their acquisition cost reported in all studies varied from 1.36 to 2.12. Both of these numbers were reported in one single study assessing several different NSAIDs in France. Thus, the GI adverse events attributable to nonselective NSAIDs are substantial, and their costs often exceed the cost of the nonselective NSAID itself.The acquisition cost of the COX-2 inhibitors was the main driver of their total cost. The GI adverse effects with the COX-2 inhibitors added 10-20% to their acquisition cost in North America, while this increase was about 50% in some European countries. Decision analysis models showed that the direct costs of COX-2 inhibitors were lower than those of nonselective NSAIDs in patients at risk of NSAID gastropathy but higher in patients at no to low risk of gastropathy. Thus, from an economic perspective, the healthcare system would benefit from treating patients at risk of NSAID gastropathy with COX-2 inhibitors, but not those at no to low risk.

Cost-effectiveness analysis of NSAIDs, NSAIDs with concomitant therapy to prevent gastrointestinal toxicity, and COX-2 specific inhibitors in the treatment of rheumatoid arthritis

The objective was to assess the cost-effectiveness of nonsteroidal anti-inflammatory agents (NSAIDs), NSAIDs with concomitant therapy to prevent gastrointestinal (GI) toxicity, and cyclooxygenase-2 specific inhibitors (COX-2) in the treatment of rheumatoid arthritis (RA). Markov (state-transition) models were used to simulate a cohort taking disease-modifying antirheumatic drugs, low dose steroid, and one of the following strategies: (1) NSAIDs without prophylaxis, (2) NSAIDs with misoprostol, (3) NSAIDs with proton-pump inhibitor (PPI), or (4) COX-2. Costs were measured in 1999 US dollars and health effects are expressed as quality-adjusted life years (QALYs). COX-2 was the most cost-effective strategy for preventing GI toxicity. The incremental cost/effectiveness (C/E) ratio between COX-2 and no prophylaxis was 56,751 dollar/QALY. Although COX-2 are the best option (among the strategies analyzed) to prevent GI toxicity, the incremental C/E ratio between COX-2 and no prophylaxis is higher than 50,000 dollar/QALY.

Selective COX-2 inhibitors: a health economic perspective

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is common in patients with osteoarthritis and rheumatoid arthritis. However, due to gastrointestinal side effects, the health-related and economic burden related to these drugs is considerable. Therefore, substituting or supplementing conventional NSAIDs with safer drugs that have a better risk profile not only may avoid serious complications but may also be an efficient allocation of scarce resources. Because of their better gastrointestinal risk profile, the newly developed selective COX-2 inhibitors celecoxib and rofecoxib are discussed as cost-effective alternatives to common NSAIDs. This paper provides an overview of health economic evaluations, conducted during the last few years, that investigate the economic consequences of switching patients from traditional NSAIDs to selective COX-2 inhibitors. This review of the health economic literature shows that results of the health economic assessments of COX-2 inhibitors are highly contradictory. The main divergence between studies occurs in estimated economic consequences of adopting COX-2 inhibitors in patients at low or average risk for developing gastrointestinal side effects. The economic consequences of the introduction of COX-2 inhibitors as well as the asynchronous development of scientific acceptance of the benefit of the new drugs and their actual diffusion and spread are discussed taking a broader, healthcare-system perspective.

Economic analysis of celecoxib versus diclofenac plus omeprazole for the treatment of arthritis in patients at risk of ulcer disease

AIM

To evaluate the economic impact of celecoxib therapy vs. diclofenac plus omeprazole therapy for the treatment of arthritis in Chinese patients with a high risk of bleeding, from the perspective of a public health organization in Hong Kong.

METHODS

The medical records of 287 Chinese arthritic patients with a history of bleeding ulcers who had previously participated in a randomised study of celecoxib 200 mg twice daily and extended-release diclofenac 75 mg twice daily plus 20 mg of omeprazole daily for 6 months were reviewed.

RESULTS

Compared to the diclofenac plus omeprazole group, the average total direct cost per patient in the celecoxib group showed a significant reduction of 11%, from HK 10,915 (range HK dollars 10,915-57,899) to HK dollars 9714 (range HK dollars 9714-89,770) (P<0.0001) (1 US dollars=7.8 HK dollars). The median direct medical cost for routine management in the celecoxib group was significantly lower (11%) than that for the diclofenac plus omeprazole group [HK dollars 10,915 (range 10,915-28,048) vs. HK dollars 9714 (range HK dollars 6946-26,179) (P<0.0001)]. In patients who experienced recurrent bleeding, the celecoxib group showed a significantly higher median cost of management of recurrent bleeding than the diclofenac plus omeprazole group [HK dollars 8466 (range 572-29,851) vs. HK dollars 23,210 (range HK dollars 12,318-65,823)] (P=0.036).

CONCLUSIONS

Celecoxib therapy appears to cost less compared with diclofenac plus omeprazole for treatment of arthritis in Chinese patients with a high risk of bleeding.

Health-related quality of life and cost of ambulatory care in osteoporosis: how may such outcome measures be valuable information to health decision makers and payers?

The objective was to quantify the outcome of osteoporosis (OP) in terms of health-related quality of life (HR-QOL) and cost of ambulatory care and to look at the association between these two outcomes variables. A cross-sectional health survey of 4800 Belgian individuals over the age of 45 years was used. Individuals having reported OP were retrieved and for each of them, at least two matched individuals for age, sex, residency location, and health insurance status were identified. All individuals were assessed with the SF-36. The two major health insurance providers furnished cost value for ambulatory care. HR-QOL and cost data were compared between the OP group and control group. Beta-coefficients from linear regression were calculated to give information on the relative importance of the association between each SF-36 dimensions and cost of ambulatory care. Of 4796 individuals appropriately surveyed, 221 (4.8%) reported OP. The control group included 651 individuals. The OP group experienced impaired HR-QOL compared to their matched counterparts, all the difference in mean or median SF-36 scores being significant at the level of P < 0.001. Osteoporotic respondents averaged 816 in cost of ambulatory care whereas controls averaged 579 (P < 0.001). When looking at detailed comparisons between categories of cost, costs in the OP group far exceeded those in the control group, all the differences being significant at the level of P < 0.001 except for home health nurse (P = 0.012). In the OP group, vitality dimensions played the most important role in the determination of cost (beta = -0.28, P < 0.001), followed by physical functioning (beta = -0.26, P < 0.01), general health, and social functioning (beta = -0.23, P < 0.01). This study evidences the burden of OP in terms of HR-QOL and cost of ambulatory care. Exploring the association between HR-QOL and cost show that mental dimension such as vitality can play an important role in the determination of cost. Conclusively, they should not be neglected in future management of OP.

Outcome trials of COX-2 selective inhibitors: global safety evaluation does not promise benefits

BACKGROUND

Gastrointestinal toxicity is the most frequent adverse effect associated with nonsteroidal anti-inflammatory drug use. The most clinically relevant side effects of this toxicity are ulcer complications, including perforation, obstruction, or bleeding. Selective cyclooxygenase (COX-2) inhibitors (coxibs) have been proposed as a safer alternative to traditional, nonsteroidal anti-inflammatory drugs and they are currently widely used in clinical practice. The aim of this review was to analyze the available evidence and then critically evaluate the outcome trials supporting the use of coxibs in terms of their clinical gastrointestinal benefits and global safety.

METHODS

All published clinical trials on selective COX-2 inhibitors were identified by searching Medline, the World Wide Web (WWW), and abstracts in Congress proceedings. From these, we selected randomized trials that clinically evaluated relevant safety outcome measures. Papers only describing endoscopic evaluation were excluded.

RESULTS

Our search yielded three outcome trials and two pooled safety analyses. The outcome studies supporting the gastrointestinal and global safety of coxibs were found to be biased in their design, analysis, and dissemination, and interpretation of a clinical benefit. Cost considerations would make the use of coxibs acceptable only in patients at high gastrointestinal risk.

CONCLUSIONS

The association of the reduced gastroerosive potential of coxibs with improved meaningful outcomes is debatable. Bias in the design of the trials, selection of outcome measures, post-hoc changes in analysis and the variables used, as well as flaws in the publication and reporting of trial results cast serious doubts on the gastrointestinal and global safety profile of coxibs. In addition, their high cost and the lack of clear identification of patients that would benefit most from treatment means the effectiveness of these drugs is uncertain at the moment.

Assessing the economic impact of adverse drug effects

Although most commonly used drugs cause adverse effects, some of them with potentially serious consequences, relatively little is known about their economic impact. The purpose of this review is to summarise information describing the cost of treatment of drug-induced adverse effects as an additional cost of pharmaceutical treatment. The focus of this study was limited to the overall economic impact of drug-related morbidity and to the economic analysis of a single class of drugs with different safety profiles. Several studies carried out in the US have investigated adverse drug effects experienced by hospitalised patients and their impact on hospital costs. Patients who developed adverse effects were hospitalised an average of 1.2-3.8 days longer than patients who did not, with additional hospital costs of $US2284-5640 per patient (2000 values). Other research studies in different countries have quantified the incidence and economic consequences of adverse drug effects that occur in the ambulatory setting and that generate hospital admission and emergency department visits. They have shown that preventable adverse effects constitute between 43.3% and 80% of all adverse outcomes leading to emergency visits and hospital admissions, and disproportionately increase healthcare costs. Finally, a recent estimation revealed that in the US the cost of problems linked to drug use in the ambulatory setting exceeded $US177 billion in the year 2000.NSAIDs constitute a widely used class of drugs and they are one of the leading drug classes in causing adverse effects. The acquisition costs of the drugs, as well as the costs for prevention and treatment of adverse effects, determine their cost-effectiveness ratio. Depending on the incidence and severity of adverse effects, the cost per adverse effect avoided ranges from $US215 to $US35 459 (2000 values). According to the contingent valuation methodology, willingness to pay to avoid or reduce the incidence of adverse effects is an indicator of the value individuals associate with the impact of such effects on their well-being. Individuals are willing to pay annually an average of $US240 and $US350, respectively, to avoid vomiting and gastrointestinal distress induced by NSAIDs. Although the results of the different studies reviewed are not strictly comparable because of differences in the severity of adverse effects, the perspective of the analysis, the cost data included and the cost component considered, the data show that, apart from the implications for health, a substantial quantity of resources are used to treat adverse effects.

Arthritis treatment in Hong Kong--cost analysis of celecoxib versus conventional NSAIDS, with or without gastroprotective agents

BACKGROUND

Selective cyclo-oxygenase-2 inhibitors have been reported to cause fewer gastrointestinal complications when compared with conventional, non-selective, non-steroidal anti-inflammatory drugs (NSAIDs).

AIM

To analyse the cost of celecoxib (selective cyclo-oxygenase-2 inhibitor) and conventional NSAID regimens for the treatment of osteoarthritis and rheumatoid arthritis from the perspective of a public health organization in Hong Kong.

METHODS

A decision tree was used to analyse the cost of celecoxib, NSAID alone, NSAID plus histamine2-receptor antagonist, NSAID plus misoprostol and NSAID plus proton pump inhibitor over 6 months. Model outcomes were no gastrointestinal toxicity, gastrointestinal discomfort, symptomatic ulcer, anaemia with occult bleeding and serious gastrointestinal complications. The clinical probabilities were estimated from clinical trials. Resource utilization for gastrointestinal events was determined locally. Sensitivity analysis was performed.

RESULTS

The 6-month costs per base-case analysis were as follows: NSAID plus histamine2-receptor antagonist, 1404 HK dollars (1 US dollar = 7.8 HK dollars); celecoxib, 1545 HK dollars; NSAID alone, 1610 HK dollars; NSAID plus misoprostol, 2213 HK dollars; NSAID plus proton pump inhibitor, 2857 HK dollars. The model was sensitive to the patients' underlying gastrointestinal risk scores, daily cost of NSAID regimen, risk ratio of NSAID plus histamine2-receptor antagonist for symptomatic ulcer, daily cost of celecoxib and daily cost of histamine2-receptor antagonist.

CONCLUSIONS

Celecoxib appeared to be the least costly alternative in patients with intermediate to high gastrointestinal risk for the treatment of osteoarthritis and rheumatoid arthritis in Hong Kong.

[Economic evaluation of a new selective COX-2 NSAID, rofecoxib, in a real practice context]

OBJECTIVE

To evaluate the economic and health consequences of the use of a new COX-2 anti-inflammatory drug.

DESIGN

Cost-effectiveness analysis by modelling three options for prescribing non-steroidal anti-inflammatories (NSAIDs) in patients diagnosed with arthrosis and undergoing long-term NSAID treatment. Option 1: NSAID prescription without gastric protection for low-risk patients, and with gastric protection for patients running a medium or high risk of developing complications (current procedure). Option 2: exclusive prescription of rofecoxib (25 mg/day) for all patients (high and low risk). Option 3: single-therapy rofecoxib (25 mg/day) prescription for patients sensitive to combined treatment (NSAIDs and gastric protection) due to the risk of complications. In each case, resources and expected clinical benefits were accounted for by the calculation of the cost of avoidance of each moderate or high gastro-intestinal side-effect (GISE) (symptomatic ulcer or complication) avoided. The direct economic impact on the centre of passing from option 1 to any of the other two options was calculated.

SETTINGS AND PARTICIPANTS

The study, conducted in the Barceloneta Primary Care Centre, included in its modelling the 124 patients diagnosed with arthrosis who received NSAIDs continuously during the year 2000.

RESULTS

Option 2 supposed avoiding 1.5 cases of GISE (0.5 symptomatic ulcers and 0.9 serious complications), to an additional cost of 336 566.78 euros. Each case avoided would cost 24,641.50 euros; and each serious case avoided 38,464.79 euros. Option 3 avoided 0.25 cases of serious complication, at an additional cost of 9,015.18 euros. Avoiding one case would cost 37,262.75 euros.

CONCLUSIONS

The overall health benefits arising from the universal or partial introduction of a selective COX-2 inhibitor NSAID involve a unit cost of 24,040.48 or 36,060.73 euros, depending on the option. The impact on the Centre s pharmaceutical budget would increase by 1.3% under option 2, and by 0.35% under option 3.

Pharmacoeconomics of coxib therapy

The economic evaluation of health care programs is undertaken to assess health care costs and benefits. Part of the goal of cost-effectiveness analysis is to maximize health benefits given the constraint of limited health care resources. The identification of costs is critical in a cost-effectiveness analysis of clinical interventions. The recent introduction of the cyclooxygenase (COX)-2-selective inhibitors, coxibs, for treatment of rheumatoid arthritis, osteoarthritis, and acute pain gives rise to cost-effectiveness issues. These new agents provide similar efficacy with fewer gastrointestinal events compared with nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), but are more expensive on a per-dose basis. However, several modeled cost analyses have suggested that COX-2 inhibitors are cost effective in subsets of patients because they are associated with fewer downstream costs, particularly medical and surgical treatment of gastrointestinal adverse effects. Three cost-effectiveness models of interventions for rheumatoid arthritis and osteoarthritis, including COX-2 inhibitors, are reviewed. Prospective clinical investigation of the potential costs and benefits of these new agents is necessary to further support these findings.

Cox-2 inhibitors: today and tomorrow

The elucidation of inducible cyclooxygenase (Cox-2) dependent inflammatory pathways led to the development of specific Cox-2 inhibitors, the coxibs. These agents include the currently available celecoxib and rofecoxib and such second-generation agents as parecoxib, valdecoxib, and etoricoxib. The therapeutic advantage of coxibs is founded primarily in their lack of significant gastrointestinal (GI) side effects. Clinical trials have demonstrated the efficacy of coxibs to be completely comparable with traditional nonsteroidal anti-inflammatory drugs (NSAIDs), and pharmacoeconomics suggest favorable cost/benefit ratios with these agents compared with traditional NSAIDs, related to their reduced GI complication profiles and lower indirect costs associated with disability. Although several clinical questions remain (eg, use with low-dose aspirin, risk of thrombosis, myocardial infarction, edema, and hypertension), the emergence and clinical utility of coxibs is likely to continue on the basis of their efficacy and relative GI safety advantage. Although newer, more specific Cox-2 inhibitors may alter the choice, it is likely that this class of anti-inflammatories will become (if they have not already) the drugs of first choice in the treatment of acute pain, chronic pain, and most rheumatic conditions in the 21st century. In addition to the treatment of rheumatic conditions, it is possible that coxibs will also be of clinical utility in protection against malignant transformation and Alzheimer disease.