Cost-effectiveness of low dose corticosteroids versus non-steroidal anti-inflammatory drugs and COX-2 specific inhibitors in the long-term treatment of rheumatoid arthritis

Objective. Non-steroidal anti-inflammatory drugs (NSAIDs) are used in nearly every patient with rheumatoid arthritis (RA) as part of a comprehensive management programme, but their use can be associated with side-effects. Low dose corticosteroid (<10 mg/day prednisone) in the treatment of RA is controversial. Although it is effective and possibly disease modifying, concerns exist about potential adverse events. We assessed costs and health effects of corticosteroids compared with NSAIDs and cyclo-oxgenase-2 (COX-2) inhibitors. Methods. Markov (state transition) models were used to simulate a cohort of RA patients taking disease-modifying antirheumatic drugs and either corticosteroids or NSAIDs. The regimens were assumed to be equally effective for the control of RA. Data on incidence, costs and consequences of adverse events from corticosteroids and from NSAIDs were taken from the literature. Costs were measured in 1999 US dollars; health effects expressed as quality-adjusted life years (QALYs). Sensitivity analyses were performed including best-case scenarios (0.5x adverse event rate) and worst-case scenarios (1.5x adverse event rate). Results. In the base-case analysis corticosteroids were superior to NSAIDs. The sensitivity analyses of adverse event rate, using best-case and worst-case scenarios, and age showed that the results were sensitive to each combination of adverse event rate and age. In contrast, the sensitivity analyses of costs and utilities were robust. Using misoprostol or omeprazole prophylaxis with NSAIDs would make corticosteroids cost-effective. Compared with NSAIDs with COX-2 specific inhibition, corticosteroids were still cost-effective. Conclusion. Corticosteroids are more cost-effective than NSAIDs and COX-2 inhibitors in the long-term treatment of RA.