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COX-2 inhibitors: complications and costs ▸
Cyclooxygenase-2 (COX-2) inhibitors have a lower risk of GI bleeding with a similar analgesia efficacy but are more expensive than NSAIDs. Spiegel et al report a systematic review on the adverse events of COX-2 compared with NSAIDs and constructed a Markov model comparing the cost-effectiveness of these two alternatives. Their meta-analysis suggested that COX-2 inhibitors had a lower risk of dyspeptic symptoms (relative risk (RR) 0.77; 95% confidence intervals (CI) 0.74 to 0.81) and clinically significant ulcer complications (RR=0.50; 95% CI 0.40 to 0.63) compared to NSAIDs. The authors assumed that all NSAID patients with dyspepsia would be investigated with endoscopy, be prescribed long term proton pump inhibitor therapy and switch to a COX-2 inhibitor. They also assumed that there would be no difference in cardiovascular events between the two options. Despite these assumptions in favour of COX-2 inhibitors the model suggested this strategy would cost $275 809/QALY gain compared with prescribing Naproxen in 60 year old patients. If patients had a previous bleeding ulcer the cost would reduce to $55 803/QALY gained. This was cost effective for US budgets but would be too expensive for the UK and many European health care systems. COX-2 inhibitors are currently too expensive to recommend as alternatives to NSAIDs for average …