The cost-effectiveness of cyclooxygenase-2 selective inhibitors in the management of chronic arthritis.

Spiegel BM, Targownik L, Dulai GS, Gralnek IM.

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.

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.

DESIGN: Cost-utility analysis.

DATA SOURCES: Systematic review of MEDLINE and published abstracts.

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

PERSPECTIVE: Third-party payer.

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

TIME HORIZON: Lifetime.

OUTCOME MEASURES: Incremental cost per quality-adjusted life-year (QALY) gained.

RESULTS OF BASE-CASE ANALYSIS: 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 OF SENSITIVITY ANALYSIS: 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.

Ann Intern Med 2003 May 20;138(10):795-806

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