The Cost-Effectiveness of Cyclooxygenase-2 Selective Inhibitors in the Management of Chronic Arthritis

20 May 2003 | Volume 138 Issue 10 | Pages 795-806

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 per year to gain 1 additional QALY.

Results of Sensitivity Analysis: The incremental cost per QALY gained decreased to $55 803 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 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.

Editors' Notes Context Relative to nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors have fewer gastrointestinal complications but cost more. The exact tradeoff between cost and effectiveness is unknown. Contribution This analysis suggests that using rofecoxib and celecoxib rather than naproxen to treat chronic arthritis is cost-effective only for patients with a previous bleeding ulcer or if the cost of COX-2 inhibitors were 10% of its current average wholesale price. Implications At current prices, COX-2 inhibitors offer a cost-effective therapeutic option for treating chronic arthritis only for patients with a previous bleeding ulcer. –The Editors

 

Author and Article Information

From the Veterans Administration Greater Los Angeles Healthcare System, David Geffen School of Medicine at University of California, Los Angeles, CURE Digestive Diseases Research Center, and Center for the Study of Digestive Healthcare Quality and Outcomes, Los Angeles, California.

Presented in part at the American Gastroenterological Association COX-2 Inhibitor Research Forum at Digestive Disease Week, May 2002, San Francisco, California.

Acknowledgments: The authors thank Emmett Keeler, PhD; Paul G. Shekelle, MD, PhD; Catherine MacLean, MD, PhD; Gerald Kominski, PhD; and A. Mark Fendrick, MD, for their thoughtful reviews of the manuscript.

Grant Support: Dr. Spiegel is supported by National Institutes of Health training grant DK-07180. Dr. Dulai is supported by National Institutes of Health K23 Career Development Award RR-16188. Dr. Gralnek is supported by a VA HSR&D Advanced Research Career Development Award.

Potential Financial Conflicts of Interest:Consultancies: I.M. Gralnek (Pharmacia); Honoraria: G.S. Dulai (Merck Pharmaceuticals), I.M. Gralnek (Merck Pharmaceuticals and Pharmacia); Grants received: I.M. Gralnek (Pharmacia).

Requests for Single Reprints: Ian M. Gralnek, MD, Veterans Administration Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, CURE Digestive Diseases Research Center, Center for the Study of Digestive Healthcare Quality and Outcomes, 11301 Wilshire Boulevard, Building 115, Room 215B, Los Angeles, CA 90073; e-mail, igralnek{at}mednet.ucla.edu.

Current Author Addresses: Drs. Spiegel, Targownik, Dulai, and Gralnek: Veterans Administration Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, CURE Digestive Diseases Research Center, Center for the Study of Digestive Healthcare Quality and Outcomes, 11301 Wilshire Boulevard, Building 115, Room 215B, Los Angeles, CA 90073.

Author Contributions: Conception and design: B.M.R. Spiegel, L. Targownik, I.M. Gralnek.

Analysis and interpretation of the data: B.M.R. Spiegel, L. Targownik, G.S. Dulai, I.M. Gralnek.

Drafting of the article: B.M.R. Spiegel, L. Targownik, G.S. Dulai, I.M. Gralnek.

Critical revision of the article for important intellectual content: B.M.R. Spiegel, L. Targownik, G.S. Dulai, I.M. Gralnek.

Final approval of the article: B.M.R. Spiegel, L. Targownik, G.S. Dulai, I.M. Gralnek.

Provision of study materials or patients: B.M.R. Spiegel, I.M. Gralnek.

Statistical expertise: B.M.R. Spiegel, L. Targownik, G.S. Dulai, I.M. Gralnek.

Obtaining of funding: I.M. Gralnek.

Administrative, technical, or logistic support: I.M. Gralnek.

Collection and assembly of data: B.M.R. Spiegel, I.M. Gralnek.