Choice of NSAID and management strategy in rheumatoid arthritis and osteoarthritis. The impact on costs and outcomes in the UK

Development of Biodegradable Injectable In situ Forming Implants for Sustained Release of Lornoxicam

OBJECTIVE

The focus of this study was to develop in situ injectable implants of Lornoxicam which could provide sustained drug release.

METHODS

Biodegradable in situ injectable implants were prepared by polymer precipitation method using polylactide-co-glycolide (PLGA). An optimized formulation was obtained on the basis of drug entrapment efficiency, gelling behavior and in vitro drug release. The compatibility of the formulation ingredients were tested by Fourier transform infrared (FT-IR) spectroscopy, and differential scanning colorimetry (DSC). SEM study was performed to characterize in vivo behavior of in situ implant. Pharmacokinetic study and in vivo gelling study of the optimized formulation were performed on Sprague-Dawley rats. Stability testing of optimized formulation was also performed.

RESULTS

The drug entrapment efficiency increased and burst release decreased with an increase in the polymer concentration. Sustained drug release was obtained up to five days. SEM photomicrographs indicated uniform gel formation. Chemical interaction between the components of the formulation was not observed by FT-IR and DSC study. Pharmacokinetic studies of the optimized formulation revealed that the maximum plasma concentration (Cmax), time to achieve Cmax (Tmax) and area under plasma concentration curve (AUC) were significantly higher than the marketed intramuscular injection of lornoxicam. Stability study of optimized batch showed no change in physical and chemical characteristics.

CONCLUSION

Lornoxicam can be successfully formulated as in situ injectable implant that provides long-term management of inflammatory disorders with improved patient compliance.

A framework for assessing the economic value of pharmacovigilance in low- and middle-income countries

Pharmacovigilance (PV) programs are an essential component of national healthcare systems. Well-functioning PV programs can improve population health by identifying and reducing medicines-related problems (MRPs). Many low- and middle-income countries lack functional PV systems, but this deficiency has not been described in terms of the potential economic value of strengthening PV systems. The assessment of economic value for PV can support rational decision making at the country level. We propose a framework for assessing the economic value of PV. We divide national PV systems into four levels: (1) no PV, (2) basic PV, (3) semi-functional PV, and (4) functional PV. These categories represent increasing levels of investment in PV capacity at the national or health facility level for all available medicines, including vaccines. The proposed framework can be used to estimate the costs of PV (including the value of investments to increase PV capacity and the costs of managing MRPs) and outcomes associated with PV (including improvements in morbidity, mortality, and quality of life as a result of the reduction in MRPs). The quantitative approach proposed for assessing costs and benefits uses a decision-analytic modeling framework that would estimate the value of the consequences of MRPs adjusted for their probability of occurrence. This allows the quantification of value using monetary outcomes (cost-benefit analysis), natural units (cost-effectiveness analysis), or mortality adjusted for quality of life or disability (cost-utility analysis). Evidence generated using this framework could assist policy makers, program managers, and donors in evaluating investments that aim to increase the capacity and efficiency of national and facility-level PV programs in low- and middle-income countries.

Cost-effectiveness analyses of osteoarthritis oral therapies: a systematic review

BACKGROUND

Cost-effectiveness analyses (CEAs) have been performed for oral non-disease-altering osteoarthritis (OA) treatments for well over a decade. During that period the methods for performing these analyses have evolved as pharmacoeconomic methods have advanced, new treatments have been introduced, and the knowledge of associated adverse events (AEs) has improved.

OBJECTIVE

The objective of this systematic review was to trace the development of CEAs for oral non-disease-altering treatments in OA.

METHODS

A systematic search for CEAs of OA oral treatments was performed of the English-language medical literature using the following databases: PubMed, EMBASE, MEDLINE In-Process, EconLit, and Cochrane. Key requirements for inclusion were that the population described patients with OA or arthritis and that the analysis reported at least one incremental cost-effectiveness ratio. Each identified publication was assessed for inclusion. Thirteen characteristics and all AEs appearing in each included CEA were extracted and organized. Reference lists from these CEAs were also searched. A chronology of key CEAs in the field was compiled, noting the characteristics that advanced the state of the art in modeling oral OA treatments.

RESULTS

Thirty publications of 28 CEAs were identified and evaluated. Developments in CEAs included an expanded set of comparators that broadened from non-steroidal anti-inflammatory drugs (NSAIDs) only to NSAIDs plus gastroprotective agents, cyclooxygenase-2 inhibitors, and opioids. In turn, AEs expanded from gastrointestinal (GI) events to also include cardiovascular (CV) and neurological events. Efficacy, which initially was presumed to be equivalent for all treatments, evolved to treatment-specific efficacies. Decision-tree analyses were generally replaced by Markov models or, occasionally, stochastic or discrete event simulation. Finally, outcomes have progressed from GI-centric measures to also include quality-adjusted life-years.

CONCLUSION

Methods used by CEAs of oral non-disease-altering OA treatments have evolved in response to changing treatments with different safety profiles and efficacies as well as technical advances in the application of decision science to health care.

Treatment costs to prevent or treat upper gastrointestinal adverse events associated with NSAIDs

The widespread use of nonselective NSAIDs and cyclo-oxygenase (COX)-2 inhibitors has a substantial impact on healthcare budgets worldwide. The cost of their gastrointestinal (GI) adverse effects is a major component of their direct cost and has received much attention in the literature. Published studies have often differed in their methodologies and results. It is important for decision makers to understand the reasons for these differences in order to make informed decisions. We conducted a literature review to summarise data that evaluate the direct costs of NSAID-related GI adverse effects worldwide. This resulted in 789 articles from which 29 studies met the inclusion criteria and were fully reviewed. Of these 29, the 9 studies that assessed the cost of COX-2 inhibitors were all based on decision economic models, compared with only 7 of the remaining 20 studies, which assessed the cost of nonselective NSAIDs. In most studies, the perspective was that of the healthcare payer and the costs assessed were reimbursement costs. Costs of GI events almost doubled between regular users and non-users of nonselective NSAIDs and were much higher in high-dose versus low-dose users. The ratio of the total cost of nonselective NSAIDs to their acquisition cost reported in all studies varied from 1.36 to 2.12. Both of these numbers were reported in one single study assessing several different NSAIDs in France. Thus, the GI adverse events attributable to nonselective NSAIDs are substantial, and their costs often exceed the cost of the nonselective NSAID itself.The acquisition cost of the COX-2 inhibitors was the main driver of their total cost. The GI adverse effects with the COX-2 inhibitors added 10-20% to their acquisition cost in North America, while this increase was about 50% in some European countries. Decision analysis models showed that the direct costs of COX-2 inhibitors were lower than those of nonselective NSAIDs in patients at risk of NSAID gastropathy but higher in patients at no to low risk of gastropathy. Thus, from an economic perspective, the healthcare system would benefit from treating patients at risk of NSAID gastropathy with COX-2 inhibitors, but not those at no to low risk.

International variation in resource utilisation and treatment costs for rheumatoid arthritis: a systematic literature review

Recent years have witnessed substantial progress in understanding the cost implications of rheumatoid arthritis (RA). To assess the divergent methodologies and their impact on the resulting cost analyses in RA, we conducted a systematic literature review to summarise the scientific evidence of RA-induced costs. Sixty-five reviews, models or cost analyses on the burden of illness and general costs associated with RA were identified. They covered the US, Canada, Sweden, the UK, The Netherlands, Germany and Finland. Twenty-four cost analyses provided appropriate data about direct and/or indirect costs. Each study was summarised separately. Costs were discounted to 2003 and converted to US dollars. The costs per RA-year ranged from USD 1503 to USD 16,514. However, each study has to be interpreted individually, with consideration given to the study population, indication, age of the study, database used, type of therapy, setting, level of cost differentiation and data derivation. Health technology assessment reports offer sufficient space to adequately describe the composite parts and restrictive elements of different methodological approaches and analyses.

Incremental cost-effectiveness of cyclooxygenase 2-selective versus nonselective nonsteroidal anti-inflammatory drugs in a cohort of coumarin users: a pharmacoeconomic analysis linked to a case-control study

BACKGROUND

A previous case-control study involving concomitant users of coumarin and nonsteroidal anti-inflammatory drugs (NSAIDs) found that cyclooxygenase 2 (COX-2)-selective NSAIDs were associated with fewer bleeding complications than nonselective NSAIDs.

OBJECTIVE

The goal of this study was to determine the incremental cost-effectiveness of COX-2-selective versus nonselective NSAIDs in relation to the occurrence of bleeding complications in a cohort of concomitant coumarin users.

METHODS

The pharmacoeconomic evaluation was linked to a case-control analysis (patients with and without bleeding complications) based on data from the earlier study in users of concomitant coumarin and NSAIDs. Medical costs associated with NSAID use and bleeding complications were estimated according to Dutch guidelines for pharmacoeconomic analyses, based on Dutch drug prices and national averages for health care costs. Rofecoxib, meloxicam, and nabumetone were considered COX-2 selective. Total costs were calculated and compared for 2 hypothetical scenarios in which patients used either COX-2-selective or nonselective NSAIDs. Sensitivity analyses were performed in which both the odds ratios (ORs) and the costs of NSAIDs and bleeding episodes were varied.

RESULTS

A total of 1,491 bleeding complications occurred in 4400 coumarin users: among the 221 (15%) NSAID users with a bleeding episode, 96% used a nonselective NSAID and 4% used a COX-2-selective NSAID. The adjusted OR of a bleeding episode for nonselective compared with COX-2-selective NSAIDs was 3.07 (95% CI, 1.18-8.03). The estimated mean cost of a bleeding episode was 478 per patient. Factoring in the excess cost of a COX-2-selective NSAID compared with a nonselective NSAID, as well as the cost savings in averted bleeding episodes, it was determined that there would be net medical cost savings of 53,800 and 162 averted bleeding episodes if the entire patient group received COX-2-selective NSAIDs rather than nonselective NSAIDs. The sensitivity analysis showed these results to be robust.

CONCLUSION

In this study population of concomitant coumarin and NSAID users, the reduction in bleeding complications with the use of more expensive COX-2-selective inhibitors was associated with net medical cost savings compared with nonselective NSAIDs.

Assessing the economic impact of adverse drug effects

Although most commonly used drugs cause adverse effects, some of them with potentially serious consequences, relatively little is known about their economic impact. The purpose of this review is to summarise information describing the cost of treatment of drug-induced adverse effects as an additional cost of pharmaceutical treatment. The focus of this study was limited to the overall economic impact of drug-related morbidity and to the economic analysis of a single class of drugs with different safety profiles. Several studies carried out in the US have investigated adverse drug effects experienced by hospitalised patients and their impact on hospital costs. Patients who developed adverse effects were hospitalised an average of 1.2-3.8 days longer than patients who did not, with additional hospital costs of $US2284-5640 per patient (2000 values). Other research studies in different countries have quantified the incidence and economic consequences of adverse drug effects that occur in the ambulatory setting and that generate hospital admission and emergency department visits. They have shown that preventable adverse effects constitute between 43.3% and 80% of all adverse outcomes leading to emergency visits and hospital admissions, and disproportionately increase healthcare costs. Finally, a recent estimation revealed that in the US the cost of problems linked to drug use in the ambulatory setting exceeded $US177 billion in the year 2000.NSAIDs constitute a widely used class of drugs and they are one of the leading drug classes in causing adverse effects. The acquisition costs of the drugs, as well as the costs for prevention and treatment of adverse effects, determine their cost-effectiveness ratio. Depending on the incidence and severity of adverse effects, the cost per adverse effect avoided ranges from $US215 to $US35 459 (2000 values). According to the contingent valuation methodology, willingness to pay to avoid or reduce the incidence of adverse effects is an indicator of the value individuals associate with the impact of such effects on their well-being. Individuals are willing to pay annually an average of $US240 and $US350, respectively, to avoid vomiting and gastrointestinal distress induced by NSAIDs. Although the results of the different studies reviewed are not strictly comparable because of differences in the severity of adverse effects, the perspective of the analysis, the cost data included and the cost component considered, the data show that, apart from the implications for health, a substantial quantity of resources are used to treat adverse effects.

Cost-Effectiveness of Prosorba Column Therapy for Rheumatoid Arthritis: A Framework for Analysis

Apheresis with the Prosorba column is safe and effective for treating refractory rheumatoid arthritis. It also is resource intensive. Economic evaluation of Prosorba column therapy could help promote efficient use of this technology. This article describes a framework and the data requirements for analyzing the cost-effectiveness of Prosorba column therapy. Several factors are considered in developing the framework including the target patient population, treatment alternatives, and clinical, economic, and quality of life outcomes of alternative treatments. We propose decision modeling as the appropriate study design because it provides a flexible framework for combining and analyzing data from different sources including experimental and nonexperimental studies. The cost-effectiveness of Prosorba column therapy will depend on the patient population in which it is used and the other treatment options still available to these patients. Offsets to the costs of providing Prosorba column therapy are likely to be largest in treatment-refractory patients and when this therapy is compared to other expensive new agents such as etanercept.

Iatrogenic cost factors incorporating mild and moderate adverse events in the economic comparison of aceclofenac and other NSAIDs

OBJECTIVE

To perform a modelled economic analysis of the efficacy and tolerability of aceclofenac in comparison with those of other nonsteroidal antiinflammatory drugs (NSAIDs) used in the treatment of common arthritic disorders including osteoarthritis, rheumatoid arthritis and ankylosing spondylitis.

DESIGN

A decision analytical model was constructed to represent the clinical and economic consequences of NSAID treatment. Probabilities of noncompliance, lack of efficacy and incidence of adverse events were obtained from comparative randomised double-blind clinical trials. Local unit treatment costs were used and an expert panel was convened to estimate resource use. Both classical foldback analysis and bootstrap methods were used to compute point estimates and 95% confidence limits of costs for NSAID treatment.

PATIENTS AND INTERVENTIONS

Data were obtained from 12 randomised double-blind clinical trials included in an earlier meta-analysis.

MAIN OUTCOME MEASURES

Total costs to the healthcare provider, including NSAID treatment costs (drug acquisition costs and physician visits for prescription) and iatrogenic costs (substitution treatment costs for patients not achieving clinical efficacy and costs of medical visits, treatment, diagnostic tests and hospital stays associated with adverse events) and the iatrogenic cost factor (ICF) were used as the primary outcome measures.

RESULTS

Means and 95% confidence intervals revealed no statistically significant differences in total costs between aceclofenac and other NSAIDs, with the exception of piroxicam, despite substantial differences in drug acquisition costs. The ICF for aceclofenac was lower than that for all other comparators, and differences in ICF between aceclofenac 200 mg/day and diclofenac 150 mg/day, indomethacin 100 mg/day, naproxen 1000 mg/day, tenoxicam 20 mg/day or ketoprofen 150 mg/day were statistically significant.

CONCLUSION

These results show that the comparative overall costs of NSAIDs bears little relation to drug acquisition cost, and that the ICF is one of the most important determinants of overall costs.