Minimizing complications from nonsteroidal antiinflammatory drugs: cost-effectiveness of competing strategies in varying risk groups.
OBJECTIVE
To appraise the cost-effectiveness of competing therapeutic strategies in patient cohorts eligible for aspirin prophylaxis with varying degrees of gastrointestinal (GI) and cardiovascular risk.


METHODS
Cost-effectiveness and cost-utility analyses were performed to evaluate 3 competing strategies for the management of chronic arthritis: 1) a generic nonselective nonsteroidal antiinflammatory drug (NSAID(NS)) alone; 2) NSAID(NS) plus a proton pump inhibitor (PPI); and 3) a cyclooxygenase 2-selective inhibitor (coxib) alone. Cost estimates were from a third-party payer perspective. The outcomes were incremental cost per ulcer complication avoided and incremental cost per quality-adjusted life year (QALY) gained. Sensitivity analysis was performed to evaluate the impact of varying patient GI risks and aspirin use.


RESULTS
In average-risk patients, the NSAID(NS) + PPI strategy costs an incremental 45,350 US dollars per additional ulcer complication avoided and 309,666 US dollars per QALY gained compared with the NSAID(NS) strategy. The coxib strategy was less effective and more expensive than the NSAID(NS) + PPI strategy. Sensitivity analysis revealed that the NSAID(NS) + PPI strategy became the dominant approach in patients at high risk for an NSAID adverse event (i.e., patients taking aspirin with > or =1 risk factor for a GI complication).


CONCLUSIONS
Generic nonselective NSAIDs are most cost-effective in patients at low risk for an adverse event. However, the addition of a PPI to a nonselective NSAID may be the preferred strategy in patients taking aspirin or otherwise at high risk for a GI or cardiovascular adverse event.
Spiegel
Brennan M R
BM
Veteran's Affairs Greater Los Angeles Healthcare System, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California 90073, USA. bspiegel@mednet.ucla.edu
Chiou
Chiun-Fang
CF
Ofman
Joshua J
JJ
D053799:2-Pyridinylmethylsulfinylbenzimidazoles; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects* / Q000191:economics; D001168:Arthritis / Q000150:complications / Q000188:drug therapy* / Q000191:economics; D001241:Aspirin / Q000627:therapeutic use; D000068579:Celecoxib; D003362:Cost-Benefit Analysis; D004359:Drug Therapy, Combination; D005767:Gastrointestinal Diseases / Q000139:chemically induced / Q000191:economics / Q000473:pathology; D006801:Humans; D007783:Lactones / Q000009:adverse effects / Q000191:economics; D064747:Lansoprazole; D009288:Naproxen / Q000009:adverse effects / Q000191:economics; D009853:Omeprazole / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000191:economics; D054328:Proton Pump Inhibitors; D011720:Pyrazoles / Q000009:adverse effects / Q000191:economics; D012219:Rheumatology / Q000191:economics*; D013449:Sulfonamides / Q000009:adverse effects / Q000191:economics; D013450:Sulfones / Q000009:adverse effects / Q000191:economics
D053799:2-Pyridinylmethylsulfinylbenzimidazoles; D000894:Anti-Inflammatory Agents, Non-Steroidal; D007783:Lactones; D054328:Proton Pump Inhibitors; D011720:Pyrazoles; D013449:Sulfonamides; D013450:Sulfones; D064747:Lansoprazole; C116926:rofecoxib; D009288:Naproxen; D000068579:Celecoxib; D009853:Omeprazole; D001241:Aspirin