title: Are COX-2 inhibitors preferable to combined NSAID and PPI in countries with moderate health service expenditures?
abstract: BACKGROUND
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Institute of Pharmacy, Military Medical Academy, Belgrade, Serbia.
authors.forename: Aneta
authors.initials: A
authors.lastname: Perić
authors.forename: Marija
authors.initials: M
authors.lastname: Toskić-Radojičić
authors.forename: Silva
authors.initials: S
authors.lastname: Dobrić
authors.forename: Nemanja
authors.initials: N
authors.lastname: Damjanov
authors.forename: Branislava
authors.initials: B
authors.lastname: Miljković
authors.forename: Mirjana
authors.initials: M
authors.lastname: Antunović
authors.forename: Sandra
authors.initials: S
authors.lastname: Vezmar
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects / Q000627:therapeutic use*; D017046:Cost Savings; D003365:Costs and Cost Analysis; D052246:Cyclooxygenase 2 Inhibitors / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D003906:Developing Countries; D017850:Economics, Pharmaceutical; D005260:Female; D005767:Gastrointestinal Diseases / Q000139:chemically induced; D005102:Health Expenditures; D006296:Health Services / Q000191:economics*; D006801:Humans; D008297:Male; D008875:Middle Aged; D054328:Proton Pump Inhibitors / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D055771:Serbia
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D052246:Cyclooxygenase 2 Inhibitors; D054328:Proton Pump Inhibitors