Long-term consequences with regard to clinical outcome and cost-effectiveness of episodic treatment with omeprazole or ranitidine for healing of duodenal ulcer

Rabeprazole is superior to ranitidine in the management of active duodenal ulcer disease: results of a double-blind, randomized North American study

OBJECTIVE

The primary purpose of this study was to compare the efficacy and tolerability of rabeprazole versus ranitidine in the treatment of patients with active duodenal ulcer disease.

METHODS

This multicenter, double-blind, randomized, parallel-group study enrolled 376 patients. Patients were randomly assigned to receive rabeprazole 20 mg administered once daily in the morning (q.a.m.) with matching ranitidine placebo twice daily (b.i.d.) (n = 188), or ranitidine 150 mg b.i.d. with matching rabeprazole placebo q.a.m. (n = 188). Three visits were scheduled: wk 0 (baseline; days -3 to -1), wk 2 (day 15+/-3 days), and wk 4 (day 29+/-3 days). The primary efficacy response variable was defined as complete regeneration of the mucosa at the site of all ulcers identified during the study. Secondary efficacy variables included patients' ratings of frequency and severity of ulcer pain, frequency of antacid use, and improvement of overall physical well-being. Tolerability was evaluated with analyses of adverse events, laboratory evaluations, fasting serum gastrin levels, vital signs, body weight, and electrocardiograms.

RESULTS

Up to 4 wk of treatment with rabeprazole 20 mg q.a.m. produced significantly greater healing rates, compared to treatment with ranitidine 150 mg b.i.d. (83% vs 73%; p = 0.017). Significant differences between treatment groups were also observed for secondary efficacy indices. At wk 2, rabeprazole was more likely than ranitidine to produce complete resolution of duodenal ulcer pain (39% vs 25%; p = 0.006), improvement in duodenal ulcer nighttime pain severity (76% vs 65%; p = 0.044), and improvement in overall well-being (55% vs 41%; p = 0.009). At wk 4, the proportion of patients with normalization of overall well-being was significantly higher in the rabeprazole group than in the ranitidine group (45% vs 29%; p = 0.003). Rabeprazole was safe and well tolerated in this study.

CONCLUSIONS

In patients with active duodenal ulcer disease, rabeprazole 20 mg q.a.m. is superior to ranitidine 150 mg b.i.d. in healing, resolving ulcer pain frequency, improving nighttime pain severity, and improving overall well-being. Rabeprazole is an effective and well-tolerated alternative treatment for patients with active duodenal ulcer disease.

Economic evaluation in gastrointestinal disease

Safety and efficacy are not the only parameters of interest in the choice of medical technology--costs are playing an increasingly important role. There is growing interest in 'value for money', which can be assessed economically by comparing the costs and consequences of alternative courses of action. A number of different economic evaluation methods may be used: cost-minimization (only costs examined with no consideration given to consequences); cost-effectiveness (in which a unidimensional clinical outcome is assessed, for example, life-years gained); cost-utility (multidimensional outcomes measured, for example quantity and quality of life); and cost-benefit (where outcome is considered in monetary terms). Ulcer disease offers several examples of how economic evaluation can be used to address issues related to efficiency and value for money in healthcare. In a study of reflux oesophagitis, omeprazole was shown to be more cost-effective than ranitidine in a 12-week treatment study. With omeprazole the costs were lower and the effectiveness better than with the H2-receptor antagonist. In a later study the cost-effectiveness of omeprazole and ranitidine are compared for both intermittent and maintenance treatment in reflux oesophagitis. Using a Markov chain approach, Swedish cost data and studying a time period of 12 months, it found that omeprazole is both more effective in providing healthy days and less costly than ranitidine for both treatment strategies. The comparison between intermittent treatment and maintenance treatment with omeprazole shows that the latter is more effective but also more costly. It is concluded that the relative cost-effectiveness of omeprazole maintenance treatment increases with the risk of relapse when off treatment, the severity of symptoms following relapse, and the value of healthy days, i.e. days free from reflux oesophagitis. A model analysis comparing Helicobacter pylori eradication with conventional treatments in patients with duodenal ulcer disease has shown H. pylori eradication to be cost-effective when compared with either episodic therapy using omeprazole or maintenance therapy with ranitidine. The study used a Markov chain approach, and included the cost of treatment, in Swedish crowns, in a Swedish primary care setting over a period of 5 years. In the analysis, patients receiving conventional therapy were initially healed with omeprazole, 20-40 mg once daily. Following healing patients were either treated with further courses of omeprazole upon relapse or were given maintenance treatment with ranitidine, 150 mg once daily. The patients who were assigned to the H. pylori eradication therapy group were initially given an H. pylori test. Those patients who proved positive for the bacterium received omeprazole, 20 mg twice daily, plus amoxicillin, 2000 mg daily in divided doses, for 2 weeks, followed by omeprazole, 20 mg once daily, for a further 2 weeks to ensure healing. Patients who were H. pylori-negative were assigned to receive either episodic or maintenance therapy as described above. The model assumption applied in the H. pylori eradication group was that, following successful healing and H. pylori eradication, virtually all patients were cured and experienced no relapse during the following 5 years. by contrast, almost all the patients assigned to episodic therapy relapsed, and during maintenance therapy with H2-receptor antagonists, most patients experienced at least one relapse. Although H. pylori eradication resulted in initial higher costs than the alternative strategies, it reduced the risk of recurrence and for most patients there were no future costs. The investment therefore paid off within a relatively short period of time. Even when unfavourable assumptions were made, such as an H. pylori eradication rate of only 50%, the H. pylori eradication strategy had a pay-off period of less than 1.3 years compared with maintenance treatment, and 3 years compared with episodic

Omeprazole. An update of its pharmacology and therapeutic use in acid-related disorders

Omeprazole, a gastric acid pump inhibitor, dose-dependently controls gastric acid secretion: the drug has greater antisecretory activity than histamine H2-receptor antagonists. Omeprazole 20 to 40 mg/day is more effective than histamine H2-receptor antagonists in the short term treatment of duodenal ulcer, gastric ulcer and reflux oesophagitis. Available data suggest that omeprazole 10 to 40 mg/day is also more effective than ranitidine in the maintenance therapy of duodenal ulcer and reflux oesophagitis. The drug is also effective in patients with duodenal ulcer, gastric ulcer or reflux oesophagitis poorly responsive to histamine H2-receptor antagonists. The efficacy of omeprazole 20 mg/day appears to be similar to that of lansoprazole 30 mg/day in the short term treatment of duodenal ulcer, gastric ulcer and reflux oesophagitis. However, most available studies have been reported in abstract form only, and 2 of 3 studies in patients with duodenal ulcer have shown greater healing rates at 2 (but not 4) weeks with lansoprazole. Helicobacter pylori eradication decreases duodenal ulcer relapse rates and appears to be associated with improved duodenal ulcer healing rates. Evidence also suggests that H. pylori eradication is associated with reduced gastric ulcer relapse rates. Omeprazole monotherapy may suppress but does not eradicate H. pylori infection. Eradication rates with omeprazole 20 or 40 mg twice daily plus amoxicillin usually up to 2 g/day (3 g/day in a few studies) for 2 weeks appear to be similar to those of standard triple therapy (bismuth salt plus metronidazole, plus tetracycline or amoxicillin) or omeprazole plus clarithromycin, although eradication rates vary widely. Omeprazole plus amoxicillin appears to be better tolerated than triple therapy and represents a first-line treatment alternative in patients with H. pylori-associated peptic ulcer disease. Omeprazole plus amoxicillin plus metronidazole appears to be more effective than omeprazole plus amoxicillin in patients with metronidazole-sensitive H. pylori infection. Omeprazole remains a treatment of choice in patients with Zollinger-Ellison syndrome. The dosages should be adjusted according to individual response. However, relatively low dosages of 10 to 40 mg/day may be sufficient in some patients. The drug has also shown promise in the treatment of children with severe reflux oesophagitis, in patients with reflux oesophagitis and coexisting systemic sclerosis, and in the prevention of aspiration pneumonia. Evidence suggests that omeprazole is more effective than ranitidine in patients with nonsteroidal anti-inflammatory drug (NSAID)-induced gastric damage who continue to take NSAIDs, especially in patients with large gastric ulcers; however, completion of ongoing studies is required to verify this.(ABSTRACT TRUNCATED AT 400 WORDS)