Brennan M.R. Spiegel, MD; Laura Targownik, MD; Gareth S. Dulai, MD, MSHS; Ian M. Gralnek, MD, MSHS
Spiegel BM, Targownik L, Dulai GS, Gralnek IM. The Cost-Effectiveness of Cyclooxygenase-2 Selective Inhibitors in the Management of Chronic Arthritis. Ann Intern Med. 2003;138:795-806. doi: 10.7326/0003-4819-138-10-200305200-00007
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Published: Ann Intern Med. 2003;138(10):795-806.
Relative to nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors have fewer gastrointestinal complications but cost more. The exact tradeoff between cost and effectiveness is unknown.
This analysis suggests that using rofecoxib and celecoxib rather than naproxen to treat chronic arthritis is cost-effective only for patients with a previous bleeding ulcer or if the cost of COX-2 inhibitors were 10% of its current average wholesale price.
At current prices, COX-2 inhibitors offer a cost-effective therapeutic option for treating chronic arthritis only for patients with a previous bleeding ulcer.
The base-case patient has chronic arthritis, is at average risk for ulcer complications, and is not taking concurrent aspirin. The clinician may either treat with naproxen, 500 mg twice daily, or with a coxib, once daily. The extended tree ( ) is shared by the coxib arm, with the exception of switching to coxibs if ulcer complications develop. See text for details about individual strategies and for assumptions about downstream costs and effects (not represented in the figure). EGD = esophagogastroduodenoscopy; GI = gastrointestinal; NUD = nonulcer dyspepsia; PPI = proton-pump inhibitor.
The summary estimate is the relative risk ( ). CLASS = Celecoxib Long-term Arthritis Safety Study; SUCCESS = Successive Celecoxib Efficacy and Safety Study.
The summary estimate is the relative risk ( ).
This analysis simultaneously varies all parameters over the full range of plausible values. Each point represents the incremental cost-effectiveness ratio generated by one trial through the simulation. The median incremental cost-effectiveness ratio of $268 000 per quality-adjusted life-year ( ) gained is shown ( ), and, by definition, 50% of the trials fall on either side. Points below and to the right of each line represent trials that generated an incremental cost-effectiveness ratio below the specified threshold. For example, if a third-party payer was willing to pay $150 000 per QALY gained for coxib therapy, then only 4.3% of the patients in this simulation would fall within the budget. WTP = willingness-to-pay thresholds.
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