A Cost‐Utility Analysis of Misoprostol Prophylaxis for Rheumatoid Arthritis Patients Receiving Nonsteroidal Antiinflammatory Drugs

Abstract

Objective. To determine the cost-utility of lowdose misoprostol prophylaxis in rheumatoid arthritis (RA) patients treated with nonsteroidal antiinflammatory drugs (NSAIDs).Methods. Prospectively collected, populationbased data on 57 RA patients' preferences (obtained using the category scaling and time trade-off techniques), charge data from a consecutive, populationbased cohort of 36 RA patients with NSAID-related gastric ulcer, and literature-derived probability estimates were incorporated into a decision analysis model. Results. Probabilistic sensitivity analysis using 10,000 Monte Carlo simulations demonstrated that, on average, prophylaxis resulted in modest additional costs and no additional quality-of-life benefits. At best, the incremental cost per quality-adjusted life year gained was $9,333. At worst, prophylaxis reduced quality of life. Prophylaxis was cost-saving if the ulcer complication rate was >1.5%, or if the 3-month price of misoprostol was ~$ 9 5 .Conclusion. Whereas prophylaxis may be costsaving among high-risk NSAID users, from some patients' perspective, it reduces quality of life. Although these data may not be generalizable to other clinical populations, they illustrate the importance of incorporating patient preferences into economic evaluations.An estimated 30 million people worldwide consume nonsteroidal antiinflammatory drugs (NSAIDs), constituting a world market in excess of $2 billion (1). NSAID-induced adverse gastrointestinal (GI) events, ranging from dyspepsia to severe complications that can lead to hospitalization, surgery, and death, have important negative effects on patient quality of life (2). While misoprostol (a prostaglandin analog) prevents the development of clinically defined NSAIDassociated gastric ulcers (3), its effectiveness on the clinically important outcomes of hemorrhage, perforation, and death is unknown, and it may result in reduced quality of life due to medication side effects. Therefore, widespread use of misoprostol prophylaxis (4) not only has potential important economic consequences to society but may also have important quality of life consequences. Of the 6 published economic evaluations of misoprostol prophylaxis (5-lo), 5 concluded that it was cost-effective. However, none of these analyses incorporated any measure of healthrelated quality of life.Using data from the literature (summarized in our metaanalysis [2]) buttressed with new populationbased estimates of costs and of rheumatoid arthritis (RA) patients' preferences (a measure of healthrelated quality of life) for all possible outcomes related to NSAID-associated gastric ulcers, we have designed a model to determine the impact on costs and on patient quality and quantity of life for 3 misoprostol prophylaxis strategies: 1) misoprostol prophylaxis for all NSAID users, 2) misoprostol prophylaxis for no NSAID users, or 3) prophylaxis for only elderly (highrisk) NSAID users.

A comparison of the cost-effectiveness of five strategies for the prevention of non-steroidal anti-inflammatory drug-induced gastrointestinal toxicity: a systematic review with economic modelling

“…Three studies reported cost-utility analyses. 12,156,170 Sixteen studies carried out costeffectiveness analysis where they incorporated probabilities into a decision-analytic model, but did not report ICERs, just expected costs.…”

“…Resource use associated with treatment pathways was obtained using expert opinion in 17 studies, 15,149,150,155,157,158,[160][161][162][163][165][166][167][168]173,175,176 patient records in five studies, 11,154,156,160,177 insurance or hospital billing in five studies, 13,157,172,174,179 national or diagnosis related group (DRG)-linked reimbursement in four studies 159,164,171,180 and was not reported in five studies. 12,153,169,170,178 …”

The clinical and cost-effectiveness of anakinra for the treatment of rheumatoid arthritis in adults: a systematic review and economic analysis

“…81,[117][118][119][120][121][122][123][124][125] Several published economic analyses of drug therapies for use in RA were also identified, relating to the use of NSAIDs, for example, see Gabriel and colleagues 126 and DMARDs. [127][128][129][130] No fully published economic evaluations of anakinra treatment for patients with RA were identified from the literature.…”

Probabilistic Analysis of Cost-Effectiveness Models: Choosing between Treatment Strategies for Gastroesophageal Reflux Disease

“…Although a number of authors have begun to emphasize the advantages of adopting a Bayesian perspective in probabilistic modeling, [27][28][29] many probabilistic analyses do not adopt a Bayesian approach, and for such studies the choice of distributions to represent uncertainty in parameters may appear rather ad hoc. [30][31][32][33][34][35][36] Furthermore, the Bayesian approach may afford a more intuitive interpretation of the probabilistic sensitivity results that has been highlighted as lacking in a review of the use of medical decision analysis models. 37 Adopting a Bayesian approach to the probabilistic analysis of the model of GERD management allows the intuitive interpretation often afforded to acceptability curves as showing the probability that the intervention is cost-effective.…”