A Review of the Efficacy, Safety, and Cost‐Effectiveness of COX‐2 Inhibitors for Africa and the Middle East Region

Abstract

Despite an increasingly sophisticated understanding of pain mechanisms, acute and chronic pain remain undertreated throughout the world. This situation reflects the large gap that exists between evidence and practice in pain management and is typified by inappropriate use of nonsteroidal anti-inflammatory drugs (NSAIDs). The scientific evidence around these drugs continues to expand at a high rate, yet physicians are often unaware of best practice. To address this gap among physicians in Africa and the Middle East, an Expert Panel meeting was convened with representatives from the region. The principal objective of the meeting was to review the latest guidelines on the management of acute and chronic pain and to review the efficacy, safety, and cost-effectiveness of cyclooxygenase-2 (COX-2) inhibitors in these settings. The main outcome of this review process was a number of consensus statements concerning the definitions of acute and chronic pain, and the efficacy, safety and cost-effectiveness of traditional nonselective NSAIDs (nsNSAIDs) and selective COX-2 inhibitors (coxibs). The panel agreed that nsNSAIDs and coxibs are effective analgesics with similar efficacy for acute pain; for chronic musculoskeletal pain, NSAIDs are significantly more effective than either placebo or paracetamol. Coxibs offer important safety advantages over nsNSAIDs, including gastrointestinal safety and preservation of platelet function; notably, the cardiovascular safety of coxibs has been the subject of much recent debate. Furthermore, the panel agreed there is substantial evidence to indicate that cost savings can be achieved by using celecoxib in patients at moderate to high risk of gastrointestinal adverse events, even in countries with moderate healthcare expenditures.

Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines

“…Cost effectiveness of interventional techniques has been demonstrated for spinal cord stimulation (531), percutaneous adhesiolysis (532), and caudal epidural injections (533) in chronic recalcitrant pain presenting to interventional pain management settings after failure of conservative modalities and often surgical interventions. Cost effectiveness of drug therapy modalities also has been demonstrated for various nonopioid drug treatments, often with clinically insignificant outcomes and higher costs than interventional therapies (518,(534)(535)(536)(537)(538)(539)(540)(541)(542)(543). A cost utility analysis showed caudal epidural injections to be effective at $2,172 for one year of qualityadjusted life year (QALY) (533), $2,650 for percutaneous adhesiolysis for one year of QALY (532), and (£) 6,392 for spinal cord stimulation for one year of QALY (531).…”

NSAIDs for Musculoskeletal Pain Management: Current Perspectives and Novel Strategies to Improve Safety

“…137 Most evaluations have arrived at similar conclusions, suggesting that coxibs should be reserved for patients at high risk for developing a serious gastrointestinal complication. 128,133 Economic models indicate a gastroprotective agent should be given with traditional NSAIDs and coxibs. 129,141 In efforts to control costs, managed care organizations and Medicaid programs have implemented utilization management strategies, such as tier placement, prior authorization, and step therapy to restrict the use of celecoxib.…”

Comparative safety of NSAIDs for gastrointestinal events in Asia‐Pacific populations: A multi‐database, international cohort study

“…Our study highlights the importance of evaluating older medicines that are used commonly in Asian countries. The use of more expensive COX‐2 inhibitors may increase the economic burden in the health care system, especially for countries with moderate income . If less costly loxoprofen and mefenamic acid pose favorable gastrointestinal safety profiles, they could play a role in curbing the high cost of pain control …”

“…The use of more expensive COX-2 inhibitors may increase the economic burden in the health care system, especially for countries with moderate income. 32 If less costly loxoprofen and mefenamic acid pose favorable gastrointestinal safety profiles, they could play a role in curbing the high cost of pain control. 6,32 This is the first multi-database, international pharmacoepidemiologic study in an Asia-Pacific population, and implementation of the study holds a number of lessons for future international pharmacoepidemiologic studies in Asia.…”