The cost-effectiveness of cyclooxygenase-2 selective inhibitors in the management of chronic arthritis

Background: Rofecoxib and celecoxib (coxibs) effectively treat chronic arthritis pain and reduce ulcer complications by 50% compared with nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). However, their absolute risk reduction is small and the cost-effectiveness of treatment is uncertain. Objective: To determine whether the degree of risk reduction in gastrointestinal complications by coxibs offsets their increased cost compared with a generic nonselective NSAID. Design: Cost-utility analysis. Data Sources: Systematic review of MEDLINE and published abstracts. Target Population: Patients with osteoarthritis or rheumatoid arthritis who are not taking aspirin and who require long-term NSAID therapy for moderate to severe arthritis pain. Perspective: Third-party payer. Interventions: Naproxen, 500 mg twice daily, and coxib, once daily. Patients intolerant of naproxen were switched to a coxib. Outcome Measures: Incremental cost per quality-adjusted life-year (QALY) gained. Results of Base-Case Analysis: Using a coxib instead of a nonselective NSAID in average-risk patients cost an incremental $275 809 per year to gain 1 additional QALY. Results of Sensitivity Analysis: The incremental cost per QALY gained decreased to $55 803 when the analysis was limited to the subset of patients with a history of bleeding ulcers. The coxib strategy became dominant when the cost of coxibs was reduced by 90% of the current average wholesale price. In probabilistic sensitivity analysis, if a third-party payer was willing to pay $150 000 per QALY gained, then 4.3% of average-risk patients would fall within the budget. Conclusions: The risk reduction seen with coxibs does not offset their increased costs compared with nonselective NSAIDs in the management of average-risk patients with chronic arthritis. However, coxibs may provide an acceptable incremental cost-effectiveness ratio in the subgroup of patients with a history of bleeding ulcers.