Cost-effectiveness of nonsteroidal anti-inflammatory drugs and opioids in the treatment of knee osteoarthritis in older patients with multiple comorbidities.
Cost-effectiveness of nonsteroidal anti-inflammatory drugs and opioids in the treatment of knee osteoarthritis in older patients with multiple comorbidities.
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DOI：
10.1016/j.joca.2015.10.006
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发表时间：
2016-03
影响因子：
7
通讯作者：
Losina E
中科院分区：
文献类型：
--
作者：
Katz JN;Smith SR;Collins JE;Solomon DH;Jordan JM;Hunter DJ;Suter LG;Yelin E;Paltiel AD;Losina E
目的：评估萘普生、布洛芬、塞来昔布或曲马多治疗合并心血管疾病(CVD)和糖尿病的骨性关节炎患者的长期临床和经济学结果。在对乙酰氨基酚和皮质类固醇注射未能控制疼痛后，我们使用骨关节炎政策模型来检查这些止痛药的治疗。对使用和不使用质子泵抑制剂(PPI)的NSAID方案进行了评估。我们评估了可用的非处方药(OTC)方案。对治疗效果(所有方案中约57%的患者疼痛减轻)和毒性(主要心脏或胃肠道毒性或骨折，风险从使用塞来昔布的1.09%到使用曲马多的5.62%)的估计来自已发表的文献。年度成本来自红皮书在线®。结果按3%/年折现，包括成本、质量调整后的预期寿命和增量成本-效果比(ICER)。在敏感性分析中，关键输入参数是不同的。将布洛芬添加到标准护理中可以节省成本，使QALY增加0.07，同时降低成本800美元。加入非处方药萘普生而不是布洛芬，增加了0.01个QALY，增加了300美元的成本，导致ICER为54,800美元/QALY。处方萘普生与非处方药PPI联合使用导致ICER为76,700美元/QALY，而处方NAPROXN与处方PPI联合使用导致ICER为252,300美元/QALY。包括曲马多或塞来昔布在内的方案成本较高，但增加的QALY较少，因此主要由几种含有萘普生的方案主导。在有多种合并症的患者中，含萘普生和布洛芬的方案在控制骨性关节炎疼痛方面比阿片类药物、塞来昔布或标准治疗方案更有效、更具成本效益。
To evaluate long-term clinical and economic outcomes of naproxen, ibuprofen, celecoxib or tramadol for OA patients with cardiovascular disease (CVD) and diabetes. We used the Osteoarthritis Policy Model to examine treatment with these analgesics after standard of care -- acetaminophen and corticosteroid injections -- failed to control pain. NSAID regimens were evaluated with and without proton pump inhibitors (PPIs). We evaluated over-the-counter (OTC) regimens where available. Estimates of treatment efficacy (pain reduction, occurring in ~ 57% of patients on all regimens) and toxicity (major cardiac or gastrointestinal toxicity or fractures, risk ranging from 1.09% with celecoxib to 5.62% with tramadol) were derived from published literature. Annual costs came from Red Book Online®. Outcomes were discounted at 3%/year and included costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios (ICERs). Key input parameters were varied in sensitivity analyses. Adding ibuprofen to standard of care was cost saving, increasing QALYs by 0.07 while decreasing cost by $800. Incorporating OTC naproxen rather than ibuprofen added 0.01 QALYs and increased costs by $300, resulting in an ICER of $54,800/QALY. Using prescription naproxen with OTC PPIs led to an ICER of $76,700/QALY, while use of prescription naproxen with prescription PPIs resulted in an ICER of $252,300/QALY. Regimens including tramadol or celecoxib cost more but added fewer QALYs and thus were dominated by several of the naproxen-containing regimens. In patients with multiple comorbidities, naproxen- and ibuprofen-containing regimens are more effective and cost-effective in managing OA pain than opioids, celecoxib or standard of care.