The cost-effectiveness of cyclooxygenase-2 selective inhibitors in the management of chronic arthritis.
BACKGROUND
Rofecoxib and celecoxib (coxibs) effectively treat chronic arthritis pain and reduce ulcer complications by 50% compared with nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). However, their absolute risk reduction is small and the cost-effectiveness of treatment is uncertain.


OBJECTIVE
To determine whether the degree of risk reduction in gastrointestinal complications by coxibs offsets their increased cost compared with a generic nonselective NSAID.


METHODS
Cost-utility analysis.


METHODS
Systematic review of MEDLINE and published abstracts.


METHODS
Patients with osteoarthritis or rheumatoid arthritis who are not taking aspirin and who require long-term NSAID therapy for moderate to severe arthritis pain.


CONCLUSIONS
Third-party payer.


METHODS
Naproxen, 500 mg twice daily, and coxib, once daily. Patients intolerant of naproxen were switched to a coxib.


METHODS
Lifetime.


METHODS
Incremental cost per quality-adjusted life-year (QALY) gained.


RESULTS
Using a coxib instead of a nonselective NSAID in average-risk patients cost an incremental 275 809 dollars per year to gain 1 additional QALY.


RESULTS
The incremental cost per QALY gained decreased to 55 803 dollars when the analysis was limited to the subset of patients with a history of bleeding ulcers. The coxib strategy became dominant when the cost of coxibs was reduced by 90% of the current average wholesale price. In probabilistic sensitivity analysis, if a third-party payer was willing to pay 150 000 dollars per QALY gained, then 4.3% of average-risk patients would fall within the budget.


CONCLUSIONS
The risk reduction seen with coxibs does not offset their increased costs compared with nonselective NSAIDs in the management of average-risk patients with chronic arthritis. However, coxibs may provide an acceptable incremental cost-effectiveness ratio in the subgroup of patients with a history of bleeding ulcers.
Spiegel
Brennan M R
BM
Veterans Administration Greater Los Angeles Healthcare System, David Geffen School of Medicine at University of California, CURE Digestive Diseases Research Center, Los Angeles, CA 90073, USA.
Targownik
Laura
L
Dulai
Gareth S
GS
Gralnek
Ian M
IM
D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D002318:Cardiovascular Diseases / Q000139:chemically induced; D000068579:Celecoxib; D002908:Chronic Disease; D003362:Cost-Benefit Analysis; D051546:Cyclooxygenase 2; D052246:Cyclooxygenase 2 Inhibitors; D016861:Cyclooxygenase Inhibitors / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use; D003661:Decision Support Techniques; D006801:Humans; D007527:Isoenzymes / Q000037:antagonists & inhibitors*; D007783:Lactones / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use; D008565:Membrane Proteins; D010003:Osteoarthritis / Q000188:drug therapy*; D010437:Peptic Ulcer / Q000139:chemically induced / Q000517:prevention & control; D011451:Prostaglandin-Endoperoxide Synthases; D011720:Pyrazoles; D019057:Quality-Adjusted Life Years; D012008:Recurrence; D012307:Risk Factors; D012680:Sensitivity and Specificity; D013449:Sulfonamides / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use; D013450:Sulfones
D000894:Anti-Inflammatory Agents, Non-Steroidal; D052246:Cyclooxygenase 2 Inhibitors; D016861:Cyclooxygenase Inhibitors; D007527:Isoenzymes; D007783:Lactones; D008565:Membrane Proteins; D011720:Pyrazoles; D013449:Sulfonamides; D013450:Sulfones; C116926:rofecoxib; D051546:Cyclooxygenase 2; C496540:PTGS2 protein, human; D011451:Prostaglandin-Endoperoxide Synthases; D000068579:Celecoxib