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.

摘要: OBJECTIVES: To assess the relative effectiveness, patient acceptability, costs and cost-effectiveness of four strategies for prevention non-steroidal anti-inflammatory drugs (NSAIDs)-induced gastrointestinal (GI) toxicity: (1) Cox-1 NSAIDs plus histamine-2 receptor antagonist (H2RA), (2) proton pump inhibitors (PPIs), (3) misoprostol, (4) Cox-2 (later expanded to 4a coxibNSAIDs 4b preferential NSAIDs). DATA SOURCES: Electronic databases up May 2002. REVIEW METHODS: Relevant studies were selected, assessed analysed. Pooled risk ratios (RR) from systematic review combined with up-to-date UK resource use unit data in an incremental economic analysis. A probabilistic decision-analytic model was designed populated carry out Incremental (ICERs) generated outcome measure, endoscopic ulcer or serious GI event averted, against total cost, non-parametric bootstrapping used simulate variance these ICERs. RESULTS: Of 118 selected trials, including 125 relevant comparisons (which included 76,322 participants) only 138 deaths 248 events reported. Seven judged be at low bias. Comparing gastroprotective placebo, there no evidence effectiveness H2RAs any primary outcomes (few reported), PPIs may reduce symptomatic ulcers [RR 0.09, 95% confidence interval (CI) 0.02 0.47], misoprostol reduces complications (RR 0.57, CI 0.36 0.91) 0.36, 0.20 0.67), 'preferentials' 0.41, 0.26 0.65) 'coxibs' 0.49, 0.38 0.62) possibly 0.55, 0.80). All except ulcers. There 12 direct between strategies. they suggest is that preferentials are better than preventing complications. Indirect suggested prevent coxibs, but this very weak evidence. For appear more successful preferentials. head-to-head published analyses regard main generally insufficient regards cardiac renal outcomes, life-years gained populate mode. Mean (2.5th 97.5th percentile) per averted compared alone as follows: H2RAs, -186 pounds (-555 804); PPIs, 454 (251 877); 54 (-112 238); selective NSAIDs, 263 (-570 1280), specific 301 (189 418). With ulcers, NSAID H2RA a dominant option. Cost-effectiveness acceptability analysis showed probability combination less costly effective. frontiers if decision-maker willing pay 750 avoid ulcer, then optimal strategy. If over pounds, strategy misoprostol. Between 1900 3750 optimal, become optimal. PPI never Sensitivity subgroup cost-effective older age group. Some conclusions we