Cost-effective Analysis of Proton Pump Inhibitors in Long-term Management of Gastroesophageal Reflux Disease: A Narrative Review

Abstract

Background: Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder that results from regurgitation of acid from the stomach into the esophagus. Treatment available for GERD includes lifestyle changes, antacids, histamine-2 receptor antagonists (H2RAs), proton pump inhibitors (PPIs), and anti-reflux surgery. Aim: The aim of this review is to assess the cost-effectiveness of the use of PPIs in the long-term management of patients with GERD. Method: We searched in PubMed to identify related original articles with close consideration based on inclusion and exclusion criteria to choose the best studies for this narrative review. The first section compares the cost-effectiveness of PPIs with H2RAs in long-term heartburn management. The other sections shall only discuss the cost-effectiveness of PPIs in 5 different strategies, namely, continuous (step-up, step-down, and maintenance), on-demand, and intermittent therapies. Results: Of 55 articles published, 10 studies published from 2000 to 2015 were included. Overall, PPIs are more effective in relieving heartburn in comparison with ranitidine. The use of PPIs in managing heartburn in long-term consumption of nonsteroidal anti-inflammatory drug (NSAID) has higher cost compared with H2RA. However, if the decision-maker is willing to pay more than US$174 788.60 per extra quality-adjusted life year (QALY), then the optimal strategy is traditional NSAID (tNSAID) and PPIs. The probability of being cost-effective was also highest for NSAID and PPI co-therapy users. On-demand PPI treatment strategy showed dominant with an incremental cost-effectiveness ratio of US$2197 per QALY gained and was most effective and cost saving compared with all the other treatments. The average cost-effectiveness ratio was lower for rabeprazole therapy than for ranitidine therapy. Conclusion: Our review revealed that long-term treatment with PPIs is effective but costly. To achieve long-term cost-effective approach, we recommend on-demand approach to treat heartburn symptoms, but if the symptoms persist, treatment with continuous step-down therapy should be applied.

Assessment of gastric-acid suppressants prescribing at an internal medicine service of a tertiary hospital in Latin America: A retrospective record review study

“…In terms of economic burden, GASs prescription leads to a progressive increase of public health costs. PPI prescriptions are estimated to cost approximately $10 billion per year in the United States (14,15) . Only in 2010, income from the sale of esomeprazole reached $13.6 billion (16) .…”

Current management of gastro-oesophageal reflux disease—treatment costs, safety profile, and effectiveness: a narrative review

“…The prevalence of GORD in the adult population varies by geographical location, with the highest rates reported in the USA (18.1%–27.8%), Middle East (8.7%–33.1%), Europe (8.8%–25.9%), South America (23%), and Australia (11.6%), and the lowest rates in East Asian countries (3%–8%) [ 5 , 8 , 9 ]. Not all of this variation can be attributed to the common risk factors for GORD (obesity, diet, alcohol consumption, tobacco smoking, aging of the population), with possible sampling, modelling, and reporting differences [ 5 ].…”

“…When comparisons are made between PPI therapy and invasive interventions for GORD, it is important to consider not only treatment efficacy but also cost-effectiveness and adverse events. Annual direct healthcare costs for PPIs exceed US$10 billion in the USA and £425 million in the UK [ 5 , 16 ]. In Australia, from 30 June 2020 to 1 July 2021, there were 15,327,811 Pharmaceutical Benefits Scheme (PBS)-subsidized prescriptions filled for pantoprazole, esomeprazole, rabeprazole, or omeprazole, costing $252,274,196 (government + patient contribution in Australian dollars) [ 2 ].…”

Efficacy of Teprenone for Prevention of NSAID-Induced Gastrointestinal Injury: A Systematic Review and Meta-Analysis

“…However, there have been concerns of increased risk of fractures, infections, and possible risk of dementia and renal disease with long-term use of PPIs ( 8 ). Furthermore, PPIs are expensive and may also affect platelet response thus reducing the efficacy of low-dose aspirin ( 9 , 10 ). A recent narrative review on the use of PPIs for long-term treatment of gastroesophageal reflux has reiterated the efficacy of PPIs but has also highlighted the high-cost associated with long term treatment ( 10 ).…”

“…Furthermore, PPIs are expensive and may also affect platelet response thus reducing the efficacy of low-dose aspirin ( 9 , 10 ). A recent narrative review on the use of PPIs for long-term treatment of gastroesophageal reflux has reiterated the efficacy of PPIs but has also highlighted the high-cost associated with long term treatment ( 10 ). Thus, an effective and safe alternative drug would enhance the spectrum of medications available to physicians for long-term prophylaxis against gastric injury.…”