Preventing non-steroidal anti-inflammatory drug-induced gastrointestinal toxicity: are older strategies more cost-effective in the general population?

OBJECTIVES To assess the relative cost-effectiveness of five gastroprotective strategies for patients in the general population not judged to be at high gastrointestinal (GI) risk requiring regular traditional (t) non-steroidal anti-inflammatory drugs (NSAIDs) for over 3 weeks: tNSAID/H(2) receptor antagonists (H(2)RAs); tNSAID/proton pump inhibitors (PPIs); tNSAID/misoprostol; COX-2 preferential NSAIDs or COX-2-specific NSAIDs (COXIBs). METHODS A systematic review of outcomes and UK cost data were combined in an incremental economic analysis. Incremental cost-effectiveness ratios were generated for quality-adjusted life years (QALYs) gained. RESULTS Cost-utility analysis showed a tNSAID with a H(2)RA is safer and less costly than tNSAIDs alone, and equally effective and less costly than COXIBs. tNSAID/misoprostol was also dominated by tNSAID/H(2)RA due to withdrawal caused by side-effects reducing overall health status. The incremental increase in QALYs gained by using COXIBs instead of tNSAID/H(2)RA would cost 670,000 pounds per QALY gained. The incremental increase in QALYs gained by using tNSAID/PPI instead of COXIBs would cost 26,000 pounds per QALY gained. If the decision-maker will pay up to 140,000 pounds per extra QALY, the optimal strategy is tNSAID/H(2)RA. If the decision-maker will pay over this the optimal strategy is tNSAID/PPI. CONCLUSION The economic analysis suggests that there may be a case for prescribing H(2)RAs in all patients requiring NSAIDs. Our recommendations are tentative due to the quality of the data available and the assumptions we have had to make in our model, and it is possible that other strategies may be preferred in patients with higher baseline GI risk.