Inpharma 1491 - 11 Jun 2005

Patient risk dictates value ofNSAID therapy in arthritis

The initial NSAID strategy of choice for patients withchronic arthritis "is highly dependent on individual riskfactors", according to the results of a modelling studyconducted by US-based researchers.

They used a decision-analysis model to compare the1-year cost effectiveness of the following three NSAIDstrategies among a hypothetical cohort of 60-year-oldpatients with chronic arthritis, who were eligible toreceive aspirin for cardiovascular prevention:• NSAIDs alone (naproxen)• NSAID + proton pump inhibitor (PPI; lansoprazole)• COX-2 inhibitor alone (celecoxib or rofecoxib).The researchers found that, as cardiovascular risk and

the risk of GI complications increased, the addition of aPPI to NSAID therapy "may be preferable" toCOX-2 inhibitor-based strategies. Overall, NSAIDs alonewas the least costly, but also the least effective, of thethree strategies, note the researchers. Among patients ataverage risk of developing an ulcer complication,* theaddition of a PPI to NSAID therapy would cost anadditional $US43 350 per ulcer complication avoided,**

or $US302 333 per quality-adjusted life-year (QALY)gained, compared with NSAIDs alone. COX-2 inhibitortherapy was more costly than NSAID plus PPI therapy,but was also less effective, and was thereforedominated.

Among low-risk patients who were not receivingaspirin, the use of NSAID plus PPI therapy orCOX-2 inhibitor therapy cost > $US60 000 per ulcercomplication avoided, compared with NSAIDs alone, or> $US300 000 per QALY gained, "a cost that issignificantly higher than most accepted interventions inmedicine", comment the researchers. However, theincremental cost-effectiveness ratios associated withNSAID plus PPI therapy improved in high-risk patientswho did not receive aspirin, compared with NSAIDsalone ($US4355 per ulcer complication avoided or$US28 000 per QALY gained). NSAID plus PPI therapywas also cost effective among low-risk patients whoreceived aspirin, at $US16 341 per ulcer complicationavoided compared with NSAIDs alone, but cost$US102 714 per QALY gained.

Among high-risk patients who received aspirin,NSAID plus PPI therapy was more effective and cost lessthan COX-2 inhibitor therapy, and was therefore thedominant strategy. Notably, in patients who receivedaspirin, COX-2 inhibitor therapy was dominated byNSAID plus PPI therapy, regardless of patients’ level ofrisk.* It was assumed that 20% of these patients received prophylacticaspirin.** Costs (2002 values) were those related to medications, physician-office visits, diagnostic procedures, hospital admission for GIcomplications, inpatient care for acute myocardial infarction (MI) andoutpatient care following acute MI, and were calculated from theperspective of a third-party payer.

Spiegel BMR, et al. Minimizing complications from nonsteroidal antiinflammatorydrugs: cost-effectiveness of competing strategies in varying risk groups. Arthritisand Rheumatism: Arthritis Care and Research 53: 185-197, No. 2, 15 Apr2005 801009792

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Inpharma 11 Jun 2005 No. 14911173-8324/10/1491-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved