Cost effectiveness of COX 2 selective inhibitors and traditional NSAIDs alone or in combination with a proton pump inhibitor for people with osteoarthritis

Abstract

Objectives To investigate the cost effectiveness of cyclooxygenase-2 (COX 2) selective inhibitors and traditional non-steroidal anti-inflammatory drugs (NSAIDs), and the addition of proton pump inhibitors to these treatments, for people with osteoarthritis. Design An economic evaluation using a Markov model and data from a systematic review was conducted. Estimates of cardiovascular and gastrointestinal adverse events were based on data from three large randomised controlled trials, and observational data were used for sensitivity analyses. Efficacy benefits from treatment were estimated from a meta-analysis of trials reporting total Western Ontario and McMaster Universities (WOMAC) osteoarthritis index score. Other model inputs were obtained from the relevant literature. The model was run for a hypothetical population of people with osteoarthritis. Subgroup analyses were conducted for people at high risk of gastrointestinal or cardiovascular adverse events. Comparators Licensed COX 2 selective inhibitors (celecoxib and etoricoxib) and traditional NSAIDs (diclofenac, ibuprofen, and naproxen) for which suitable data were available were compared. Paracetamol was also included, as was the possibility of adding a proton pump inhibitor (omeprazole) to each treatment. Main outcome measures The main outcome measure was cost effectiveness, which was based on quality adjusted life years gained. Quality adjusted life year scores were calculated from pooled estimates of efficacy and major adverse events (that is, dyspepsia; symptomatic ulcer; complicated gastrointestinal perforation, ulcer, or bleed; myocardial infarction; stroke; and heart failure). Results Addition of a proton pump inhibitor to both COX 2 selective inhibitors and traditional NSAIDs was highly cost effective for all patient groups considered (incremental cost effectiveness ratio less than £1000 (€1175, $1650)). This finding was robust across a wide range of effectiveness estimates if the cheapest proton pump inhibitor was used. In our base case analysis, adding a proton pump inhibitor to a COX 2 selective inhibitor (used at the lowest licensed dose) was a cost effective option, even for patients at low risk of gastrointestinal adverse events (incremental cost effectiveness ratio approximately £10 000). Uncertainties around relative adverse event rates meant relative cost effectiveness for individual COX 2 selective inhibitors and traditional NSAIDs was difficult to determine. Conclusions Prescribing a proton pump inhibitor for people with osteoarthritis who are taking a traditional NSAID or COX 2 selective inhibitor is cost effective. The cost effectiveness analysis was sensitive to adverse event data and the specific choice of COX 2 selective inhibitor or NSAID agent should, therefore, take into account individual cardiovascular and gastrointestinal risks.

American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee

“…In the clinical scenario where the above patient has had an upper GI bleed within the past year and the practitioner still chooses to use an oral NSAID, the TEP strongly recommends using a COX-2 selective inhibitor in combination with a proton-pump inhibitor. Subsequent to the initial meeting of the TEP, Latimer and colleagues reported that the addition of a proton-pump inhibitor to either a nonselective or COX-2 selective NSAID is cost effective given the evolving evidence base for efficacy and reductions in price (30). Therefore, whenever an NSAID is used for the chronic management of patients with knee or hip OA, the practitioner should consider adding a proton-pump inhibitor to reduce the risk of development of symptomatic or complicated upper GI events.…”

NSAIDs for Musculoskeletal Pain Management: Current Perspectives and Novel Strategies to Improve Safety

“…126 Despite the availability of inexpensive NSAID treatment options, this potential financial benefit may be offset by the cost associated with preventing or treating NSAID-related complications. 128,129 Numerous studies have compared the safety, effectiveness, and cost of competing strategies regarding celecoxib versus traditional NSAIDs alone or in combination with gastroprotective agents. Studies confirm the efficacy of gastroprotective agents such as PPIs in preventing NSAID-induced gastrointestinal complications.…”

“…128,133 Economic models indicate a gastroprotective agent should be given with traditional NSAIDs and coxibs. 129,141 In efforts to control costs, managed care organizations and Medicaid programs have implemented utilization management strategies, such as tier placement, prior authorization, and step therapy to restrict the use of celecoxib. Studies have shown that these tools effectively reduce utilization and expenditures for the drug, but whether these restrictions confer positive health outcomes and lower costs is not clear.…”

Outpatient management of knee osteoarthritis

“…Proton-pump inhibitors should be prescribed for their gastroprotective effects when NSAIDs are used for chronic pain management for knee OA. (13,14) If pain control is still not achieved, tramadol is added.…”