Cost effectiveness of COX 2 selective inhibitors and traditional NSAIDs alone or in combination with a proton pump inhibitor for people with osteoarthritis.
Cost effectiveness of COX 2 selective inhibitors and traditional NSAIDs alone or in combination with a proton pump inhibitor for people with osteoarthritis.
复制标题
COX 2选择性抑制剂和传统NSAID的成本效益或与质子泵抑制剂结合使用的骨关节炎患者。
DOI：
10.1136/bmj.b2538
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发表时间：
2009-07-14
期刊：
影响因子：
--
通讯作者：
National Institute for Health and Clinical Excellence Osteoarthritis Guideline Development Group
中科院分区：
文献类型：
--
作者：
Latimer N;Lord J;Grant RL;O'Mahony R;Dickson J;Conaghan PG;National Institute for Health and Clinical Excellence Osteoarthritis Guideline Development Group
目的探讨环氧化酶-2 （COX 2）选择性抑制剂和传统非甾体抗炎药（NSAIDs）治疗骨关节炎患者的成本效益，以及在这些治疗中添加质子泵抑制剂。设计使用马尔可夫模型和系统评价的数据进行了经济评价。心血管和胃肠道不良事件的估计基于三个大型随机对照试验的数据，观察性数据用于敏感性分析。从治疗中获得的疗效是通过对西安大略和麦克马斯特大学（WOMAC）骨关节炎指数评分的meta分析来估计的。其他模型输入来自相关文献。该模型是在假设的骨关节炎患者人群中运行的。对胃肠道或心血管不良事件高风险人群进行亚组分析。比较已获得许可的COX 2选择性抑制剂（塞来昔布和依托昔布）和传统非甾体抗炎药（双氯芬酸、布洛芬和萘普生）的数据。还包括扑热息痛，以及在每次治疗中添加质子泵抑制剂（奥美拉唑）的可能性。主要结局指标主要结局指标为成本效益，以获得的质量调整生命年为基础。质量调整生命年评分是根据疗效和主要不良事件（即消化不良、症状性溃疡、并发胃肠道穿孔、溃疡或出血、心肌梗死、中风和心力衰竭）的汇总估计来计算的。结果：在COX 2选择性抑制剂和传统非甾体抗炎药的基础上添加质子泵抑制剂对所有患者组都具有很高的成本效益（增量成本效益比小于1000英镑）。如果使用最便宜的质子泵抑制剂，这一发现在广泛的有效性估计中是稳健的。在我们的基本案例分析中，将质子泵抑制剂添加到COX 2选择性抑制剂（以最低许可剂量使用）是一种具有成本效益的选择，即使对于胃肠道不良事件风险低的患者也是如此（增量成本效益比约为10,000英镑）。相对不良事件发生率的不确定性意味着个体COX 2选择性抑制剂和传统非甾体抗炎药的相对成本效益难以确定。结论：对于正在服用传统非甾体抗炎药或COX 2选择性抑制剂的骨关节炎患者，处方质子泵抑制剂具有成本效益。成本-效果分析对不良事件数据敏感，因此，COX 2选择性抑制剂或非甾体抗炎药的具体选择应考虑个体心血管和胃肠道风险。
Objectives To investigate the cost effectiveness of cyclo-oxygenase-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.
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