Rethinking the laryngopharyngeal reflux treatment algorithm: Evaluating an alternate empiric dosing regimen and considering up-front, pH-impedance, and manometry testing to minimize cost in treating suspect laryngopharyngeal reflux disease

OBJECTIVES/HYPOTHESIS

Empiric proton pump inhibitor (PPI) trials for laryngopharyngeal reflux (LPR) are common. A majority of the patients respond to acid suppression. This work intends to evaluate once-daily, 40 mg omeprazole and once-nightly, 300 mg ranitidine (QD/QHS) dosing as an alternative regimen, and use this study's cohort to evaluate empiric regimens prescribed for LPR as compared to up-front testing with pH impedance multichannel intraluminal impedance (MII) with dual pH probes and high-resolution manometry (HRM) for potential cost minimization.

STUDY DESIGN

Retrospective cohort review and cost minimization study.

METHODS

A chart review identified patients diagnosed with LPR. All subjects were treated sequentially and outcomes recorded. Initial QD/QHS dosing increased after 3 months to BID if no improvement and ultimately prescribed MII and HRM if they failed BID dosing. Decision tree diagrams were constructed to determine costs of two empiric regimens and up-front MII and HRM.

RESULTS

Ninety-seven subjects met the criteria. Responders and nonresponders to empiric therapy were identified. Seventy-two subjects (74%) responded. Forty-eight (67% of responders and 49% of all) improved with QD/QHS dosing. Forty-nine (51%) subjects escalated to BID dosing. Twenty-four subjects (33% of responders and 25% of all) improved on BID therapy. Twenty-five subjects (26%) did not respond to acid suppression. Average weighted cost was $1,897.00 per patient for up-front testing, $3,033.00 for initial BID, and $3,366.00 for initial QD/QHS.

CONCLUSIONS

An alternate QD/QHS regimen improved the majority who presented with presumed LPR. Cost estimates demonstrate that the QD/QHS regimen was more expensive than the initial BID high-dose PPI for 6 months. Overall per-patient cost appears less with up-front MII and HRM.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:S1-S13, 2017.

The impact of generic substitution on price competition in Finland

Generic substitution by pharmacists was introduced in April 2003 in Finnish pharmaceutical markets. This article examines the impact of generic substitution on price development. This study examined all of the 2,100 substitutable drugs in Finland. The impact of generic substitution on price competition was significant. The average price of substitutable drugs decreased by more than 10%. However, the price development was uneven; some prices increased whereas others decreased by more than 50%. The most important factors that influenced the price development were the number of competitors, whether the drug was originator or generic and the width of the price band.

[Cost-effectiveness analysis for the treatment of non-erosive reflux disease]

Non-erosive reflux disease(NERD) is a common condition and acid-suppressing agents are the mainstay of treatment. A cost-effectiveness analysis comparing a PPI, lansoprazole (LPZ) and a H2RA, ranitidine (RAN) for the treatment of NERD in Japan was performed using a decision analysis. The time period studied was one month and payer or patient' s perspective was considered. Efficacy data were estimated from a randomized clinical trial. Expected days without symptom (healthy days) were 20 for LPZ 15 mg/day and 16 for RAN 300 mg/day. Direct costs were 4,750 yen for LPZ and 4,358 yen for RAN. Cost-effectiveness ratio (direct costs/healthy days) was 238 yen for LPZ and 272 yen for RAN. Considering the results from a large-scale survey of GERD patients in Japan, the slightly higher price of LPZ was outweighed by its greater efficacy, also from the patient's willingness to pay perspective. Lansoprazole was superior to ranitidine with regard to both efficacy and cost-effectiveness and therefore is the preferred therapeutic agent for treatment of NERD.

Pharmaco-economic considerations in the long-term management of peptic ulcer disease

Pharmaco-economic consequences of available therapeutic strategies in the management of duodenal ulcer disease are of increasing importance. Terminology and methodology in economic evaluation need to be clarified: direct and indirect costs of duodenal ulcer disease have to be calculated, and results expressed in terms of efficacy, utility or benefits. The economic analysis then compares costs or cost-effectiveness ratios of various strategies. Macro-economic evaluations conducted in France have shown that the overall cost of duodenal ulcer disease was FF 3.5 billion in 1987 in private practice. Several evaluations have shown that indirect costs accounted for more than 50% of the total expense. From a microeconomic point of view, several studies have been conducted with ranitidine and cimetidine. Our own study has shown that one year of treatment with ranitidine 150 mg/day resulted in a decrease in the use of medical resources (clinic visits, endoscopic investigations, duration of hospital stay) and work days lost, when compared with placebo. This resulted in a smaller cost of the ranitidine strategy (FF 2031 per patient for one year for the community, vs. FF 2823 for the placebo strategy). Similar cost-effectiveness ratios for the ranitidine strategy have been shown in the USA. Costs savings have also been demonstrated during long-term treatment with cimetidine for up to 3 years. Studies performed according to Markov's chain model have shown that the costs of continuous and intermittent treatments are identical, the expenses related to investigations and mortality being greater with the latter. More studies are warranted to evaluate the efficiency of the different strategies used in the treatment of duodenal ulcer disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacoeconomic comparison of Helicobacter pylori eradication regimens

BACKGROUND

Helicobacter pylori is the most important etiologic agent for development of peptic ulcer, chronic gastritis and gastric carcinomas. It is now well established that H. pylori eradication treatment is more cost-effective than acid suppressing therapies alone for the treatment of peptic ulcer disease. However, the comparative cost-effectiveness of various H. pylori eradication regimens is still not clear.

OBJECTIVE

This study was designed to make a pharmacoeconomic comparison of different H. pylori eradication regimens in patients with peptic ulcer disease or chronic gastritis, using real-world cost and effectiveness data.

SETTING

Istanbul University Hospital and Marmara University Hospital.

METHOD

A total of 75 patients diagnosed as H. pylori (+) by endoscopy were randomized to receive one of the seven H. pylori treatment protocols. These protocols were as follows: (LAC) = 'lansoprazole 30 mg bid + amoxicillin 1 g bid + clarithromycin 500 mg bid' for 7 days and (OCM) = 'omeprazole 20 mg bid + clarithromycin 250 mg bid + metronidazole 500 mg bid'; (OAM) = 'omeprazole 40 mg qd + amoxicillin 500 mg tid + metronidazole 500 mg tid'; (MARB) = 'metronidazole 250 mg tid + amoxicillin 500 mg qid + ranitidine 300 mg hs + bismuth 300 mg qid'; (OAC) = omeprazole 20 mg bid + amoxicillin 1 g bid + clarithromycin 500 mg bid'; (OCA) = omeprazole 40 mg bid + clarithromycin 500 mg bid + amoxicillin 1 g bid'; (OAB) = 'omeprazole 20 mg bid + amoxicillin 500 mg tid + bismuth 300 mg qid' each for 14 days. Only direct costs were included in the analysis. Effectiveness was measured in terms of "successful eradication". The cost-effectiveness ratios of the regimens were calculated using these effectiveness and cost data. The perspective of the study was assumed as the Government's perspective.

MAIN OUTCOME MEASURE

Cost-effectiveness ratios of eradication regimens.

RESULTS

MARB and OCA regimens were found to be more cost-effective than the other treatment regimens. The eradication rates and cost-effectiveness ratios calculated for these protocols were 90% (158.7 euros) for MARB and 90% (195.8 euros) for OCA regimen.

CONCLUSION

This study confirms the importance of using local pharmacoeconomic data. Analyses such as this give decision-makers the tools to choose a better treatment option which is both highly effective yet and has a low cost.

Impact of Helicobacter pylori eradication on dyspepsia, health resource use, and quality of life in the Bristol helicobacter project: randomised controlled trial

OBJECTIVE

To determine the impact of a community based Helicobacter pylori screening and eradication programme on the incidence of dyspepsia, resource use, and quality of life, including a cost consequences analysis.

DESIGN

H pylori screening programme followed by randomised placebo controlled trial of eradication.

SETTING

Seven general practices in southwest England.

PARTICIPANTS

10,537 unselected people aged 20-59 years were screened for H pylori infection (13C urea breath test); 1558 of the 1636 participants who tested positive were randomised to H pylori eradication treatment or placebo, and 1539 (99%) were followed up for two years.

INTERVENTION

Ranitidine bismuth citrate 400 mg and clarithromycin 500 mg twice daily for two weeks or placebo.

MAIN OUTCOME MEASURES

Primary care consultation rates for dyspepsia (defined as epigastric pain) two years after randomisation, with secondary outcomes of dyspepsia symptoms, resource use, NHS costs, and quality of life.

RESULTS

In the eradication group, 35% fewer participants consulted for dyspepsia over two years compared with the placebo group (55/787 v 78/771; odds ratio 0.65, 95% confidence interval 0.46 to 0.94; P = 0.021; number needed to treat 30) and 29% fewer participants had regular symptoms (odds ratio 0.71, 0.56 to 0.90; P = 0.05). NHS costs were 84.70 pounds sterling (74.90 pounds sterling to 93.91 pounds sterling) greater per participant in the eradication group over two years, of which 83.40 pounds sterling (146 dollars; 121 euro) was the cost of eradication treatment. No difference in quality of life existed between the two groups.

CONCLUSIONS

Community screening and eradication of H pylori is feasible in the general population and led to significant reductions in the number of people who consulted for dyspepsia and had symptoms two years after treatment. These benefits have to be balanced against the costs of eradication treatment, so a targeted eradication strategy in dyspeptic patients may be preferable.

"Proton-pump inhibitor-first" strategy versus "step-up" strategy for the acute treatment of reflux esophagitis: a cost-effectiveness analysis in Japan

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common condition, and acid-suppressing agents are the mainstays of treatment. For the acute medical management of GERD, two different strategies can be proposed: either the most effective therapy, i.e., proton-pump inhibitors (PPIs), can be given first, or histamine H2-receptor antagonists (H2RAs) can be attempted first (the "step-up" approach).

METHODS

A clinical decision analysis comparing the PPI-first strategy and the H2RA-first "step-up" strategy for the acute treatment of reflux esophagitis in Japan was performed, using a Markov chain approach.

RESULTS

The PPI-first strategy was consistently superior to the step-up strategy with regard to clinical outcomes for the patient and with regard to cost-effectiveness (direct cost per patient to achieve clinical success). This superiority was robust within the plausible range of probabilities according to the sensitivity analyses.

CONCLUSIONS

The PPI-first strategy is superior to the H2RA-first "step-up" strategy with regard to both efficacy and cost-effectiveness and therefore, the PPI-first strategy is the preferred therapeutic approach for the acute medical treatment of reflux esophagitis.

A randomized trial comparing omeprazole, ranitidine, cisapride, or placebo in helicobacter pylori negative, primary care patients with dyspepsia: the CADET-HN Study

BACKGROUND

The management of Helicobacter pylori negative patients with dyspepsia in primary care has not been studied in placebo-controlled studies.

METHODS

H. pylori negative patients with dyspepsia symptoms of at least moderate severity (> or =4 on a seven-point Likert scale) were recruited from 35 centers. Patients were randomized to a 4-wk treatment of omeprazole 20 mg od, ranitidine 150 mg bid, cisapride 20 mg bid, or placebo, followed by on-demand therapy for an additional 5 months. Treatment success was defined as no or minimal symptoms (score < or = 2 out of 7), and was assessed after 4 wk and at 6 months.

RESULTS

Five hundred and twelve patients were randomized and included in the intention-to-treat (ITT) analysis. At 4 wk, success rates (95% CI) were: omeprazole 51% (69/135; 43-60%), ranitidine 36% (50/139, 28-44%), cisapride 31% (32/105, 22-39%), and placebo 23% (31/133, 16-31%). Omeprazole was significantly better than all other treatments (p < 0.05). The proportion of patients who were responders at 4 wk and at 6 months was significantly greater for those receiving omeprazole 31% (42/135, 23-39%) compared with cisapride 13% (14/105, 7-20%), and placebo 14% (18/133, 8-20%) (p= 0.001), but not ranitidine 21% (29/139, 14-27%) (p= 0.053). The mean number of on-demand study tablets consumed and rescue antacid used was comparable across groups. Economic analysis showed a trade-off between superior efficacy and increased cost between omeprazole and ranitidine.

CONCLUSION

Treatment with omeprazole provides superior symptom relief compared to ranitidine, cisapride, and placebo in the treatment of H. pylori negative primary care dyspepsia patients.

Six-month management of patients following treatment for gastroesophageal reflux disease symptoms -- a Norwegian randomized, prospective study comparing the costs and effectiveness of esomeprazole and ranitidine treatment strategies in a general medical practitioners setting

This study assesses the difference in direct medical costs between on-demand treatment with esomeprazole 20 mg, continuous treatment with esomeprazole 20 mg once-daily and continuous treatment with ranitidine 150 mg twice-daily to prevent symptomatic relapse in patients with gastroesophageal reflux disease over 26 weeks. Two hundred eighty-one GP clinics in Norway enrolled 2156 patients to an open, randomized, parallel group, Norwegian society perspective study during 2000-2001. The total direct medical costs of each strategy were 171.9 Euros for on-demand esomeprazole (n = 634), 221.6 Euros for ranitidine (n = 610) and 248.8 Euros for continuous esomeprazole (n = 658). The total costs for on-demand and continuous esomeprazole treatment and ranitidine treatment were 221.5, 286.5 and 295.8 Euros, respectively. The highest proportion of costs was because of the study medication cost in each strategy. The on-demand and continuous treatment strategies with esomeprazole were found to be cost-effective, compared with ranitidine.

Drug costs developments after patent expiry of enalapril, fluoxetine and ranitidine: a study conducted for the Netherlands

BACKGROUND

In order to increase price competition, government regulations focus on controlling drug costs. Drug costs after patent expiry are an area of particular interest because the substitution of branded medication with generics represents an opportunity for lowering drug costs. However, drug costs may not decrease after patent expiry, because of a lack of price competition and different national pricing systems.

AIM

The aim of this study was to investigate the trends in the use of generics after patent expiry for enalapril, fluoxetine and ranitidine and the subsequent changes, if any, in the costs of these medications.

METHODS

A drug-utilisation study was performed using data from a large sample of Dutch pharmacies. Both volumes (measured as defined daily doses [DDD] per 1000 population) as well as drug costs (calculated per DDD) prior to and after patent expiry were calculated. Costs per DDD were compared using trend-line analysis. In addition, the relative market shares of the different trade channels (branded, parallel imported and generic) were compared before and after patent expiry.

RESULTS

The costs per DDD decreased for all three drugs and, as expected, these costs decrease more rapidly after patent expiry. Significant differences in the trend lines were found for enalapril and fluoxetine.

CONCLUSIONS

Despite relatively high reimbursement prices for generics in the Netherlands, this example from the Dutch pharmaceutical market demonstrates the benefit of generic substitution for containing pharmaceutical costs, which contrasts with concerns raised by the Dutch government.

A practice-based approach for converting from proton pump inhibitors to less costly therapy

CONTEXT

Projected cost for lansoprazole, the formulary proton pump inhibitor (PPI) at our institution, was $1.8 million in 1999. While some patients require PPI therapy, many could control their symptoms with a histamine H2-receptor antagonist blocker (H2 blocker) at a much lower cost.

OBJECTIVE

To evaluate a practice-based approach to converting patients from PPIs to H2 blockers.

DESIGN

Before-after study.

SETTING

Portland Veterans Affairs Primary Care Clinics.

INTERVENTION

We developed guidelines and educated clinicians about the use of PPIs and H2 blockers. To help physicians convert appropriate patients from PPIs to H2 blockers, we gave them a list of their patients receiving PPIs, form letters for patients explaining the conversion, and structured prescription forms. Patient lists and e-mail reminders, as well as feedback on institutional performance, were sent to clinicians during the intervention period.

OUTCOME MEASURES

Number of PPI and H2 prescriptions per enrollee and pharmacy costs.

RESULTS

The average number of PPI prescriptions per enrollee at our institution decreased from 0.39 in the 9 months before the intervention to 0.27 in the 9 months after the intervention. The associated pharmacy costs decreased from an average of $43 to $28 per enrollee per quarter, a difference of $15 or a savings of $80,000 per quarter. Accounting for the decrease in medication prices during the study, this difference was $11 per patient per quarter, corresponding to a savings of about $60,000 per quarter. With respect to the conversion process, more than 70% of clinicians felt the intervention had a big impact on how they prescribed PPIs and H2 blockers. Eighty-two percent of clinicians converted patients from PPIs to H2 blockers during clinic time; 56% did so during administrative time. Overall, more clinicians considered the intervention to be helpful rather than a hassle.

CONCLUSIONS

The number of PPI prescriptions decreased during the intervention and was sustained at least three quarters afterward. This low-intensity, practice-based intervention may serve as a model for other health care systems.

Impact of the Minimum Pricing Policy and introduction of brand (generic) substitution into the Pharmaceutical Benefits Scheme in Australia

PURPOSE

To describe the effects of introducing the Minimum Pricing Policy (MPP) and generic (brand) substitution in 1990 and 1994 respectively on the dispensing of Pharmaceutical Benefits Scheme (PBS) prescriptions both at the aggregate and individual patient level.

METHODS

The relative proportion of prescriptions with a brand premium and those at benchmark was examined 4 years after introduction of the MPP and again 5 years later after generic substitution by pharmacists was permitted. To determine the impact of a price signal at the individual level, case studies involving a patient tracking methodology were conducted on two drugs (fluoxetine and ranitidine) that received a brand premium.

RESULTS

From a zero base when the MPP was introduced in 1990, there were 5.4 million prescriptions (17%) dispensed for benchmark products 4 years later in 1994. At this stage generic (brand) substitution by pharmacists was then permitted and the market share of benchmark brands increased to 45% (25.2 million) by 1999. In the patient tracking studies, a significantly lower proportion of patients was still taking the premium brand of fluoxetine 3 months after the introduction of a price signal compared with patients taking paroxetine which did not have a generic competitor. This was also the case for the premium brand of ranitidine when compared to famotidine. The size of the price signal also had a marked effect on dispensing behaviour with the drug with the larger premium (fluoxetine) showing a significantly greater switch away from the premium brand to the benchmark product.

CONCLUSIONS

The introduction in 1990 of the Minimum Pricing Policy without allowing generic substitution had a relatively small impact on the selection of medicines within the Pharmaceutical Benefits Scheme. However the effect of generic substitution at the pharmacist level, which was introduced in December 1994, resulted in a marked increase in the percentage of eligible PBS items dispensed at benchmark. Case studies showed a larger premium resulted in a greater shift of patients from drugs with a brand premium to the benchmark alternative.

Helicobacter pylori-positive duodenal ulcer: three-day antibiotic eradication regimen

BACKGROUND

The most widely used treatments for ulcer healing and Helicobacter pylori eradication consist of a 1-2 week regimen of a proton pump inhibitor plus two or three antimicrobials.

AIMS

To evaluate the efficacy, safety, cost, and tolerance of a three-day regimen with three antibiotics vs. a 10-day treatment with a proton pump inhibitor or vs. a ranitidine bismuth citrate triple therapy.

METHODS

Two hundred and twenty-one patients with endoscopically-proven H. pylori-positive duodenal ulcers were recruited to the study. Recruited patients were assigned to one of the following four regimens: (I) omeprazole 40 mg o.m. plus amoxycillin 1 g b.d. and clarithromycin 500 mg b.d. for 10 days (OAC: 55 patients); (ii) omeprazole 40 mg o.m. on days 1-5, plus amoxycillin 1 g b.d., clarithromycin 500 mg b.d. and metronidazole 500 mg b.d. on days 3-5 (OACM: 56 patients); (iii) ranitidine bismuth citrate 400 mg b.d. plus amoxycillin 1 g b.d. and clarithromycin 500 mg b.d. for 10 days (RAC: 54 patients); (iv) ranitidine bismuth citrate 400 mg b.d. on days 1-5, plus amoxycillin 1 g b.d., clarithromycin 500 mg b.d. and metronidazole 500 mg b.d. on days 3-5 (RACM: 56 patients). Fisher's exact test was used to compare data regarding healing and eradication in the four groups.

RESULTS

The intention-to-treat eradication and ulcer healing rates for the RACM regimen were 95% and 98%, respectively. Statistically significant differences were observed, relating to the eradication and healing of ulcers, between RACM and either the RAC or OAC regimens.

CONCLUSION

The three-day antibiotic therapy with amoxycillin, clarithromycin and metronidazole in addition to ranitidine bismuth citrate is a very effective anti-H. pylori regimen.

Cost effectiveness of rabeprazole versus generic ranitidine for symptom resolution in patients with erosive esophagitis

OBJECTIVE

To compare the cost effectiveness of rabeprazole (RAB) and ranitidine (RAN) in acute and maintenance therapy for erosive esophagitis using symptom response, rather than endoscopic healing, as the clinical outcome.

STUDY DESIGN

Decision analysis was used to model the cost effectiveness of competing therapies based on the results of clinical trials of RAB versus RAN and estimates from the medical literature.

METHODS

The model's base case scenario compared brand-name RAB (estimated average wholesale price) with generic RAN (25% of the average wholesale price of brand-name RAN). Medical costs for hospitalizations, procedures, and office visits reflected 1998 Medicare payments. The 1-year maintenance model accounted for drug-class switching and symptomatic, rather than endoscopic, recurrences. Effectiveness was reported as the percentage of patients in whom a symptomatic recurrence was prevented. The cost per symptomatic recurrence prevented was reported as an average and an incremental cost-effectiveness ratio.

RESULTS

The per-patient cost of RAB therapy was higher than that of RAN therapy ($2020 vs $1917); RAB therapy, however, was more effective than RAN therapy in preventing symptomatic recurrences (74% vs 41%). The average cost-effectiveness ratio was lower for RAB therapy than for RAN therapy ($2748 per symptomatic recurrence prevented vs $4719 per symptomatic recurrence prevented). The cost of preventing one additional symptomatic recurrence with RAB rather than RAN was $313 (incremental cost-effectiveness ratio). Sensitivity analysis conducted on key clinical and cost variables supported the robustness of the decision model.

CONCLUSION

This analysis demonstrates that management of esophagitis with RAB is more effective, and may be more cost effective, than management with generic RAN, despite RAB's higher per-unit cost.

Effectiveness and costs of omeprazole vs ranitidine for treatment of symptomatic gastroesophageal reflux disease in primary care clinics in West Virginia

OBJECTIVE

To compare clinical, health-related quality of life (HRQL), and medical cost outcomes in patients with symptomatic gastroesophageal reflux disease (GERD) receiving omeprazole sodium or ranitidine hydrochloride treatment.

METHODS

A multicenter, randomized, open-label, medical effectiveness trial conducted in 5 university-based family medicine clinics. Two hundred sixty-eight patients with GERD were recruited and randomly assigned to omeprazole sodium, 20 mg once daily, or ranitidine hydrochloride, 150 mg twice daily, for up to 6 months. Main outcome assessments included the Gastrointestinal Symptom Rating Scale (GSRS) Reflux score, Psychological General Well-Being Index, and Short-Form-36 Health Survey administered at baseline and 2, 4, 12, and 24 weeks. Medical resource use and cost data were collected.

RESULTS

More omeprazole-treated patients reported improved heartburn resolution at 2 weeks (49.0% vs 33.3%; P=.007) and 4 weeks (58.6% vs 35.0%; P<.001) compared with ranitidine-treated patients. The GSRS Reflux scores across 3 months showed overall differences between omeprazole (mean, 2.67) and ranitidine (mean, 2.95) groups (P=.04). Mean total 6-month medical costs were $915 lower ($8371 vs $9286; P=.64), and no difference in mean outpatient medical costs ($1198 vs $1158; P=.76) were observed in the omeprazole group compared with the ranitidine group. A post hoc secondary analysis showed that, at 12 and 24 weeks, patients treated with omeprazole for 8 weeks or more reported greater heartburn resolution (ie, 24 [43%] of 56 patients at both intervals) than patients treated with ranitidine for 8 weeks or more (12 [24%] and 13 [26%] of 50 patients, respectively; P=.001).

CONCLUSIONS

Ranitidine and omeprazole were both effective at improving heartburn symptoms; however, omeprazole provided greater resolution of heartburn symptoms at 2 and 4 weeks. Despite omeprazole's higher acquisition cost, there were no significant differences in total or outpatient costs between groups.

Test and treat strategies for Helicobacter pylori in uninvestigated dyspepsia: a Canadian economic analysis

BACKGROUND

Recognition of the pivotal role of Helicobacter pylori in the pathogenesis of peptic ulcer disease has revolutionized primary care approaches to dyspepsia. Decision analysis was used to compare the cost effectiveness of empirical ranitidine with a test and treat strategy using either H pylori serology or the 13carbon-urea breath test (13C-UBT).

PATIENTS AND METHODS

A cohort of patients under age 50 years presenting with uninvestigated dyspepsia was evaluated. Three initial strategies were compared with respect to direct medical costs and effectiveness in curing H pylori-related ulcers - empirical ranitidine, H pylori serology and UBT. A one-year time horizon and third-party payer perspective were adopted in a Canadian health care setting.

RESULTS

UBT was more costly than either serology or ranitidine but was the most effective strategy and required the fewest endoscopies. No strategy demonstrated dominance over another in the base case. The incremental cost effectiveness ratio (ICER) of serology versus ranitidine was $118/cure, and sensitivity analysis induced dominance of serology in several plausible scenarios. The baseline ICER of UBT versus serology was $885/cure but showed substantial variation in sensitivity analysis. Each ICER was highly sensitive to variation in the cost of the tests themselves. At a serology cost of $25, UBT became dominant when its cost fell to $39.

CONCLUSIONS

In low risk patients with uninvestigated dyspepsia, testing for H pylori using serology appears to be economically attractive. 13C-UBT may be a cost effective alternative to serology if local conditions closely approximate the model parameters. Future changes in the costs of serology and 13C-UBT may determine the optimal approach.

Costs and benefits of a test-and-treat strategy in Helicobacter pylori-infected subjects: a prospective intervention study in general practice

OBJECTIVE

To identify health outcomes and costs/savings of a Helicobacter pylori test-and-treat strategy in patients using acid suppressants chronically.

DESIGN

Prospective intervention study. Patients were tested for H. pylori infection and treated with 14 days of ranitidine bismuth citrate (RBC) 400 mg (b.i.d.) and clarithromycin 500 mg if infected. Cure was determined after six months.

SETTING

General practice.

PARTICIPANTS

Patients using acid suppressants chronically were identified by a computer search; 184 patients gave written consent and were included.

MAIN OUTCOME MEASURES

Serology, symptom questionnaire, medication history, quality of life determination, costs/savings.

RESULTS

Out of 184 patients, 85 (46%) had positive serology. A cure rate of 61/80 (76%) was achieved. The intervention group showed significant symptom relief. Benefits were evident in patients with ulcer disease but also in patients with uninvestigated dyspepsia. Quality of life improved for cured patients in the intervention group. No improvements for dyspeptic symptoms or quality of life occurred in the H. pylori-negative group. After six months, significant savings for medication use had occurred in treated patients diagnosed as ulcer disease or non-ulcer dyspepsia. Savings on drug use and doctor visits equalize with costs for tests and antibiotics after nine months. Although less, costs for drugs also decreased significantly in the H. pylori-negative group. Therefore, for the study population, costs and savings are even after 6.5 months.

CONCLUSIONS

A test-and-treat strategy for H. pylori, systematically applied at the population level in patients using acid suppressants chronically, results in significant health benefits and economic savings within 1 year of follow-up.

The use of intravenous H2-receptor antagonists in a tertiary care hospital

OBJECTIVE

The rationale for the widespread use of intravenous H2 receptor antagonists(IVH2 RA) in hospitalized patients is not clear. We therefore examined prescribing patterns and, using strict criteria, determined whether use was appropriate. Cost of administration and potential savings were also determined.

METHODS

Data were obtained prospectively on 100 consecutive patients prescribed intravenous ranitidine and retrospectively on patients admitted with gastrointestinal (GI) bleeding.

RESULTS

For the prospective study, various indications for prescribing intravenous ranitidine were given, including postoperative patients and patients treated with steroids. Using criteria from published literature 80% of the use was considered inappropriate. Nearly 40% of the doses were given while the patient was tolerating oral intake. Creatinine clearance was impaired in 26% of patients, though only one had dosage reduction. Estimated annual cost of intravenous ranitidine was $317,000. The retrospective study of 86 consecutive patients admitted with GI bleeding revealed that all patients received intravenous ranitidine on admission, none of which was considered appropriate. The final diagnoses were peptic ulcer (49), colonic process (11), esophagitis (seven), gastric erosions (five), esophageal varices (five), Mallory-Weiss tears (four), duodenitis (two), no diagnosis (three), and jejunal ulcer (one).

CONCLUSIONS

Inappropriate use of intravenous ranitidine is common. This includes inappropriate indication, dosage, and duration of use. Large financial benefits could have been obtained if close attention was given to prescribing patterns.

Cost effectiveness of omeprazole and ranitidine in intermittent treatment of symptomatic gastro-oesophageal reflux disease

OBJECTIVE

This 1-year study compared the cost effectiveness of omeprazole and ranitidine when used as initial therapy in an intermittent treatment strategy for the management of patients with symptomatic gastro-oesophageal reflux disease with or without erosive oesophagitis.

DESIGN AND SETTING

A prospective health economic analysis was conducted alongside an international multicentre randomised, double-blind clinical study. The economic analysis was performed from a societal perspective.

PATIENTS

A total of 704 patients in the UK, the Republic of Ireland, Germany, France, Italy and Spain were randomised to 1 of the 3 treatment groups.

INTERVENTIONS

Patients were randomised to receive either omeprazole 20 mg once daily, omeprazole 10 mg once daily or ranitidine 150 mg twice daily. Initial treatment failure resulted in dose titration and drug switching from ranitidine to omeprazole, and subsequently open maintenance treatment.

MAIN OUTCOME MEASURES AND RESULTS

The estimated mean direct medical costs (medication and number of visits and endoscopies) were found to be lower for both dosages of omeprazole than for ranitidine in all countries except Germany. However, none of the differences were statistically significant. The differences between omeprazole 10 mg and omeprazole 20 mg were small and nonsignificant. With regard to numbers of symptom-free days, both omeprazole 20 mg and omeprazole 10 mg were found to be more effective than ranitidine. However, none of the differences were statistically significant.

CONCLUSIONS

Following a pragmatic interpretation, incorporating intermediate short term results, the results in this study give no support to the notion that a step-up approach, either as dose titration from omeprazole 10 mg to omeprazole 20 mg or as drug switching from ranitidine to omeprazole, will result in cost savings and thereby be cost effective.

Antibiotic therapy of Helicobacter pylori infection reduces healthcare expenditures related to duodenal ulcer

OBJECTIVE

To test whether eradication of Helicobacter pylori saves costs in the treatment of duodenal ulcer disease, compared with conventional antisecretory therapy.

STUDY DESIGN

A prospective, double-blind clinical trial was conducted at 132 sites in the United States.

PATIENTS AND METHODS

Adult patients with active duodenal ulcer and confirmed H pylori infection were randomized to receive treatment with clarithromycin plus omeprazole, omeprazole alone, or ranitidine alone. Utilization of ulcer-related healthcare resources was documented during 1 year following therapy. Costs were calculated by multiplying the number of health resources utilized by the cost of each resource. Resource costs were obtained from a database containing actual average costs spent by managed care organizations on outpatient and inpatient treatment.

RESULTS

Of the 819 patients enrolled, 727 completed the study: 243 received clarithromycin plus omeprazole, 248 omeprazole alone, and 236 ranitidine alone. Ulcer-related health resource utilization and total ulcer-related healthcare costs were decreased after treatment with clarithromycin plus omeprazole, compared to treatment with omeprazole or ranitidine alone. In multivariate linear regression analyses, type of treatment was found to be a significant predictor of total costs. Specific costs associated with endoscopic examinations, clinic visits, and medications were also significantly reduced by treatment with clarithromycin plus omeprazole as compared to other treatment forms.

CONCLUSIONS

In a managed care environment, therapy with clarithromycin and omeprazole to eradicate H pylori in patients with duodenal ulcer disease would result in significant cost savings secondary to a reduction in the utilization of healthcare resources.

The pharmacoeconomic impact of antimicrobial therapy for peptic ulcer disease in a large urban jail

PURPOSE

To determine the pharmacoeconomic impact of antimicrobial treatment of peptic ulcer disease (PUD) in a large urban jail.

PATIENTS AND METHODS

Retrospective comparison of PUD-related pharmacy and laboratory expenditures over a 2-year period before and after the institution of a PUD treatment protocol with the priority of Helicobacter pylori eradication for inmates in Rikers Island Correctional Facility.

RESULTS

After the protocol was adopted, total pharmacy-related and laboratory-related expenses for PUD care decreased by 40.2%, and expenditures for ranitidine declined by 52.2%. There was an increase in spending for antimicrobial agents and H. pylori antibody testing, but this was insignificant compared to the savings generated by decreased ranitidine usage. Annual savings in our facility as a result of this intervention were $123,449.

CONCLUSIONS

Modern therapeutic strategies for PUD aimed at eradicating H. pylori can result in significant savings in the institutional setting; these savings are largely attributable to the decreased usage of histamine-2 receptor antagonists.

Antiulcer drug prescribing in hospital successfully influenced by "immediate concurrent feedback"

OBJECTIVE

To determine whether immediate concurrent feedback (ICF) focused on inpatient omeprazole prescribing achieved more rational and cost-effective antiulcer drug prescribing and usage.

METHODS

In a 1400-bed teaching hospital, an audit (by specially trained personnel) was conducted to monitor inpatient prescribing of omeprazole (1) in preference to H2-antagonists and other drugs according to agreed criteria (Helicobacter pylori eradication, severe reflux esophagitis, rapid ulcer healing deemed urgent because of severe symptoms or complications, high-dose steroid therapy of > or =30 mg/day prednisolone) and (2) appropriateness of intravenous dosing (oral route not feasible or contraindicated). After baseline monitoring for 1 month, followed by relevant antiulcer drug therapy education, ICF was instituted for 1 year. This entailed explanatory memoranda requesting a change in prescribing issued to the respective medical teams of patients whose omeprazole prescription did not "conform." The main outcomes of the study were omeprazole prescription numbers per month and the proportion conforming, defined daily doses of antiulcer drugs used and corresponding expenditures, and pertinent antiulcer drug utilization data from 9 other local hospitals.

RESULTS

Baseline omeprazole prescribing conformed in 32 of 173 (18%) of the patients compared with 451 of 546 (83%) during institution of ICF (P < 0001; chi2 test). Correspondingly, average overall omeprazole and ranitidine usage (inpatient and outpatient) and expenditure decreased (44% and 45%, respectively); collectively, use of less expensive alternatives increased about 61%. Estimated savings averaged about HK$150,000 ($20,000) per month. No comparable changes in usage were noted in 9 other local hospitals.

CONCLUSION

Regarding hospital antiulcer drugs, this ICF strategy was associated with more rational prescribing and usage, and an important saving of resources.

H2-antagonist maintenance therapy versus Helicobacter pylori eradication in patients with chronic duodenal ulcer disease: a prospective study

BACKGROUND

Few outcome studies directly compare Helicobacter pylori eradication therapy with maintenance H2-antagonist therapy in duodenal ulcer disease.

AIM

To examine prospectively the efficacy of H. pylori eradication therapy with ranitidine maintenance therapy over 1 year in patients with confirmed chronic duodenal ulcer.

METHODS

One hundred and nineteen patients with active H. pylori infection were randomized to receive ranitidine, 150 mg/day initially (58 patients), or omeprazole, 40 mg/day, amoxycillin 2 g/day and metronidazole 1.2 g/day for 14 days, or omeprazole 40 mg/day and clarithromycin 1.5 g/day, for 14 days (if penicillin-allergic). Symptoms were assessed using the Gastrointestinal System Rating Scale (GSRS) and SF36 quality of life index.

RESULTS

13C urea breath testing confirmed overall treatment success in 100% of patients (58/58) per protocol and 95.1% (58/61) on an intention-to-treat basis. At 4 and 12 months there were no differences in any GSRS symptoms between treatment groups. SF36 analysis showed a perceived health improvement at 4 and 12 months in patients who received H. pylori eradication. However, despite successful H. pylori eradication, one-fifth of patients still required antisecretory therapy.

CONCLUSION

Following successful H. pylori eradication, chronic duodenal ulcer patients were at least as well symptomatically as when taking maintenance ranitidine. They perceived that their health had improved, but a subgroup was still acid-suppression dependent.

Cost savings in duodenal ulcer therapy through Helicobacter pylori eradication compared with conventional therapies: results of a randomized, double-blind, multicenter trial. Gastrointestinal Utilization Trial Study Group

BACKGROUND

We hypothesized that treatment of duodenal ulcer disease with antibiotic therapy directed toward Helicobacter pylori infection is more cost-effective than therapy with antisecretory agents.

METHODS

A randomized, double-blind, multicenter clinical trial of adult patients with active duodenal ulcer and H. pylori infection was conducted. Patients were randomized to receive 500 mg of clarithromycin 3 times a day plus 40 mg of omeprazole daily for 14 days followed by 20 mg of omeprazole daily for an additional 14 days (group 1), 20 mg of omeprazole daily for 28 days (group 2), or 150 mg of ranitidine hydrochloride twice a day for 28 days (group 3). The use of ulcer-related health care resources was documented during monthly interviews for 1 year after the initial therapy. Clinical success was evaluated 4 to 6 weeks and 1 year after the end of therapy.

RESULTS

Of the 819 patients enrolled, 727 completed the study. Group 1 included 243 patients; group 2, 248 patients; and group 3, 236 patients. Patients in group 1 used fewer ulcer-related health care resources during the 1 year after therapy compared with groups 2 and 3 (comparisons are given as group 1 vs group 2 and group 1 vs group 3, respectively): the number of endoscopies performed, 28 vs 76 (P<.001) and vs 71 (P<.001); patients receiving drugs to treat an ulcer, 118 vs 180 (P<.001) and vs 168 (P<.001); clinic visits, 83 vs 135 (P=.05) and vs 161 (P<.001); hospitalizations, 0 vs 5 (P=.045) and vs 6 (P=.02); and length of hospital stay, 0 vs 24 days (P=.04) and vs 37 (P=.04). When ulcer-related costs were defined as the outcome variable in a multivariate linear regression analysis, therapy was determined to have a significant influence on costs (group 1 vs group 2, P<.001; group 1 vs group 3, P=.008). Clinical success rates at the end of the study and cure of H. pylori infection were significantly greater in group 1 compared with groups 2 and 3 (P<.001). Therapy with clarithromycin plus omeprazole provided savings of $1.94 and $2.96 (compared with therapy with omeprazole and with ranitidine hydrochloride, respectively) per dollar spent within the first year after therapy. This incremental cost-benefit translates to savings of $547 or $835 per patient in group 1 (compared with patients in group 2 or group 3, respectively) during the first year after therapy.

CONCLUSIONS

Combination therapy with clarithromycin and omeprazole resulted in significantly fewer uses of ulcer-related health care resources than conventional antisecretory therapy during a 1-year follow-up and significant savings in associated costs during the same period. Patients who received clarithromycin plus omeprazole also showed a significantly improved clinical outcome compared with patients who received only omeprazole or ranitidine.

Management of nonsteroidal anti-inflammatory drug-associated lesions: a cost-effectiveness perspective

Results are presented from a cost-effectiveness analysis of the acute healing phases of two new clinical studies. Acute treatment with omeprazole, 20 mg once daily, is compared with misoprostol, 200 microg four times daily, or ranitidine, 150 mg twice daily, in patients with nonsteroidal anti-inflammatory drug (NSAID)-associated gastroduodenal lesions (gastric ulcer, duodenal ulcer, and/or >10 erosions in either the stomach or duodenum). The cost-effectiveness comparisons indicate that omeprazole is cost-effective when compared with ranitidine in the treatment of gastric ulcers, duodenal ulcers, and erosions only, and that omeprazole is cost-effective when compared with misoprostol in the treatment of gastric ulcers and duodenal ulcers. In patients with erosions only, misoprostol is cost-effective when compared with omeprazole. When assessing the uncertainty of these estimates, a definite conclusion can be made in only two comparisons: omeprazole is cost-effective when compared with ranitidine in the treatment of gastric ulcers, and misoprostol is cost-effective when compared with omeprazole in the treatment of erosions only. However, the clinical studies were not powered for assessing the cost-effectiveness of the treatment alternatives, which impedes the uncertainty assessment. The determinants of the cost-effectiveness of prophylactic strategies are also discussed, as well as the need for further studies that include relevant outcome measures and a design that reflects actual clinical practice.

A cost-utility analysis comparing omeprazole with ranitidine in the maintenance therapy of peptic esophageal stricture

BACKGROUND

Recent studies have suggested that patients receiving omeprazole for prophylaxis against peptic esophageal stricture recurrence have less dysphagia and require fewer repeat dilations than patients receiving ranitidine.

OBJECTIVE

To estimate the incremental utility gain and associated incremental cost of omeprazole compared with those of ranitidine for the maintenance therapy of patients with peptic stricture who required esophageal dilation.

METHODS

Decision analysis using SMLTREE software was used to compare the incremental cost-utility of omeprazole 20 mg once daily with that of ranitidine 150 mg bid for one year. Variables were estimated from the literature, hospital data, and utility analyses involving patients with peptic stricture and health professionals. The primary outcome measure was cost per quality-adjusted life-years (QALYs) gained.

RESULTS

The incremental cost of omeprazole compared with that of ranitidine was $556 per patient treated. The incremental utility gain of omeprazole was 0.0112 QALYs. Overall, the incremental cost:utility ratio of omeprazole in the maintenance therapy of patients with peptic stricture was $49,600 per QALY gained. A sensitivity analysis revealed that the estimates with the greatest impact on the cost:utility ratio were disutility associated with dysphagia and dilation, the probability of requiring redilation and the cost of medications.

CONCLUSIONS

Omeprazole 20 mg once daily is associated with greater utility and higher cost than ranitidine 150 mg bid when used as prophylaxis against stricture recurrence. Omeprazole may be considered clinically and economically sufficient enough to warrant widespread use in this setting.

Cost effectiveness of treatment for gastro-oesophageal reflux disease in clinical practice: a clinical database analysis

BACKGROUND

Previous evaluation of the cost effectiveness of antireflux medication used in gastro-oesophageal reflux disease (GORD) have been based on results obtained in controlled clinical trials. Unfortunately such an approach does not necessarily identify the therapeutic option which provides the greatest benefit from available resources in real life situations. To make an informed choice requires a recognition that the costs and benefits of therapy in practice may differ from those identified in trials.

AIMS

To evaluate, based on a retrospective prescription database analysis, the cost effectiveness of alternative treatment options for patients with uncomplicated GORD. The analysis assesses health service resource use during the first six months of treatment in three groups of patients initially prescribed cisapride (CIS), ranitidine (RAN), or omeprazole (OME).

METHODS

The MediPlus UK database was used to identify all health care resources consumed by patients in the three treatment groups during their first six months of treatment. Patients with more complicated GORD, as indicated by initial referral to a specialist or outpatient hospital visit (< 13%), were excluded from the analysis.

RESULTS

The average cost per patient for the initial six months of treatment for CIS, RAN, and OME based therapies was 136 Pounds, 177 Pounds, 189 Pounds per patient, respectively. A major element underlying this cost variation was the acquisition cost and quantity of antireflux medication required by patients. The average number of one month equivalent prescriptions consumed during this six month period was 1.85 (CIS), 2.57 (RAN), and 2.96 (OME) with associated costs of 49 Pounds (CIS), 67 Pounds (RAN), and 105 Pounds (OME). Antacid and alginate/antacid use was higher in the CIS and RAN groups (about 1.0 antacid prescription per patient versus 0.4 for OME), but their contribution to the total cost per patient was less than 2%. The number of general practitioner consultations over the six month period for each treatment group was 2.4 (CIS), 2.9 (RAN), and 2.6 (OME) with associated costs of 60.31 Pounds (CIS), 73.06 Pounds (RAN), and 65.52 Pounds (OME). The average number of non-drug interventions (referrals, outpatient visits, endoscopies, barium meals, or x rays) was 0.34 in the RAN group compared with less than 0.2 in the CIS and OME groups. The costs associated with such interventions were 23.80 Pounds (RAN), 9.60 Pounds (CIS), and 11.10 Pounds (OME) per patient.

CONCLUSION

The data indicate that the "step up" approach, starting with a prokinetic or H2 receptor antagonist, represents the most cost effective initial therapeutic strategy for a primary care physician to adopt when faced with a patient with first diagnosis of uncomplicated GORD.

How Zantac became the best-selling drug in history

Glaxo's Zantac began its dominance of the acid/peptic marketplace with a launch strategy, taking advantage of the established Roche sales force to rapidly promote the product. Educational symposia for physicians were instrumental in disseminating both disease and product information to primary care physicians and specialists. This technique not only pleased physicians (more referrals), but also increased public awareness of gastrointestinal disease, further expanding the patient market. Several novel marketing strategies contributed to Zantac's success, including the public-service announcements, celebrity media tours, and consumer-awareness bulletins, which brought the drug to the lay public and encouraged individuals to seek advice from their physicians.

Proton pump inhibitors or histamine-2 receptor antagonists for the prevention of recurrences of erosive reflux esophagitis: a cost-effectiveness analysis

OBJECTIVES

Erosive esophagitis is a recurring condition for which many patients require preventive therapy. If maintenance therapy must be provided, the most cost-effective treatment strategy should be established. We evaluated the costs and benefits associated with three treatment strategies: 1) maintenance therapy with a proton pump inhibitor (PPI) strategy, 2) maintenance therapy with a high-dose histamine-2 receptor antagonist (H2RA) strategy, and 3) maintenance therapy with a standard-dose H2RA. If patients experience a symptomatic recurrence on the H2RA strategies, they then receive PPI maintenance.

METHODS

We used a cost-effectiveness model with a 1-yr time frame; data were obtained from randomized trials of lansoprazole and ranitidine, from case series, and expert opinion.

RESULTS

In most situations, the high-dose H2RA strategy is the most costly, yet it is less effective than the PPI strategy. Among the remaining two options, the PPI strategy is more costly and more effective than the standard-dose H2RA strategy, requiring an additional $52-688 per recurrence prevented, depending on drug acquisition costs. The greater the degree to which esophagitis decreases quality of life, the more cost effective is the PPI strategy. For example, with a $50,000 per quality-adjusted life year cost-effectiveness threshold and a market-weighted average of drug costs, the PPI strategy appears cost effective for those patients who report that symptoms of esophagitis cause greater than a 9% decrement in quality of life.

CONCLUSIONS

The high-dose H2RA strategy is not preferred in terms of either costs or benefits. The PPI strategy appears cost effective relative to the standard-dose H2RA strategy in the following situations: when patients are significantly bothered by esophagitis and in institutional settings where the difference in drug costs between PPIs and H2RAs is small.

Helicobacter pylori eradication in duodenal ulcer disease is cost-beneficial: a Belgian model

The eradication of Helicobacter pylori in infected patients with gastroduodenal ulcer disease the allows to obtain a definite healing of this chronically relapsing condition for which the direct costs have been steadily increasing (while indirect costs were reduced) for the last two decades. Both short-term studies performed on real time, and prospective simulations using a Markov's model over periods of one, five and up to fifteen years, revealed a significant cost/benefit advantage of an eradication policy: according to the Belgian model, the eradication of HP in patients with peptic ulcer would save between 750,000 and one million US dollars by million inhabitants when compared to maintenance or episodic treatment with anti-secretory drugs. Nevertheless, models are very sensitive to several factors: eradication rate, costs of screening and HP status assessment, frequency of peptic ulcer disease.

Lifetime costs of surgical versus medical treatment of severe gastro-oesophageal reflux disease in Finland

BACKGROUND

Gastro-oesophageal reflux disease (GERD) can be effectively treated pharmacologically or surgically. As GERD is often a chronic condition, we compared the long-term costs of medical and surgical management.

METHODS

The medical regimens were ranitidine (150 or 300 mg/day), omeprazole (20 or 40 mg/day), and lansoprazole (30 mg/day), with costs calculated for total life expectancy after diagnosis and for one-third of that time. Costs for open or laparoscopic surgery (Nissen fundoplication) included pre- and post-operative investigations, sick leave, and calculated financial loss due to fatal outcome.

RESULTS

Costs were lowest with ranitidine, 150 mg/day, for one-third of the patient's lifetime and highest with lifelong omeprazole, 40 mg/daily. The cost of open or laparoscopic operation was less than that of lifelong daily treatment with proton pump inhibitors or ranitidine, 300 mg daily.

CONCLUSION

In Finland, antireflux surgery for GERD is cheaper than lifetime treatment with proton pump inhibitors.

Triple therapy with ranitidine or lansoprazole in the treatment of Helicobacter pylori-associated duodenal ulcer

OBJECTIVE

The aim of this study was to verify the efficacy--in the cure of duodenal ulcer associated H. pylori infection--of ranitidine 300 mg taken late in the evening or lansoprazole 30 mg taken before breakfast, coupled with clarithromycin and metronidazole.

METHODS

Eighty patients with endoscopically proven active duodenal ulcer were randomized to take ranitidine or lansoprazole for 4-8 wk, together with clarithromycin 250 mg b.i.d. and metronidazole 500 mg b.id. for the first 2 wk. Endoscopic controls, as well as histological and urease tests for H. pylori, were performed at entry and after 4 and 8 wk.

RESULTS

According to intent-to-treat analysis, ulcers were healed after 4 wk in 36/40 patients (90%) with ranitidine and in 38/40 (95%) with lansoprazole. After 8 wk, the healing percentage with ranitidine and lansoprazole was 97% (39/40) and 95% (38/40), respectively. H. pylori was eradicated in 85% of the patients taking ranitidine and in 90% of those taking lanzoprazole. Side effects were reported in 25% of the patients in both groups.

CONCLUSIONS

Our results confirm that the combination of ranitidine, clarithromycin, and metronidazole can be considered an alternative to proton pump inhibitors in terms of clinical efficacy and economy.

[Triple ranitidine therapy in Helicobacter pylori infection. Recommendation for effective, safe and cost effective combination for Helicobacter pylori eradication]

Peptic ulcer disease induced by infection with Helicobacter pylori can be cured by eradicating the organism. In the meantime, such eradication therapy has moved beyond the experimental stage and can now be applied in the doctor's office, effectively, safely and inexpensively. A seven to twelve day course of treatment comprising a gastric acid inhibitor (20 mg omeprazole twice daily is no more effective than 300 mg ranitidine daily), 500 mg metronidazole twice daily, and 1 g amoxicillin twice daily results in an eradication rate of about 90%. That is, repeat treatment is needed in only one in ten patients. The cost of eradication therapy, however, varies considerably: the treatment recommended by the "initiative in support of the new form of ulcer treatment" costs DM 512.27, while equally effective treatment using generics costs only about one-fifth of this amount. In this way, a troublesome illness that for thousands of years has received only symptomatic treatment and whose sequelae cause high costs can now be treated causally with a high success rate and also a favourable cost-benefit ratio.

Omeprazole or ranitidine plus metoclopramide for patients with severe erosive oesophagitis. A cost-effectiveness analysis

The objective of this study was to evaluate the clinical and economic effects of 2 clinical strategies for treating severe (grade II and above) erosive oesophagitis or poorly responsive gastro-oesophageal reflux disease. A single-blind, randomised controlled trial of up to 8 weeks' duration was undertaken comparing omeprazole with ranitidine plus metoclopramide in patients with severe and symptomatic erosive oesophagitis (endoscopic grade II and above). Two cost-effectiveness ratios were calculated: cost per healed patient and cost per symptom-free day. The study perspective was that of the payer or insurer of medical care. Healing rates were significantly higher among omeprazole-treated patients than among those who received ranitidine/metoclopramide at 4 weeks (68.5% vs 30.4%; p < 0.01) and overall (81.5% vs 45.7%; p < 0.01). Overall, mean gastrointestinal-related direct medical costs per healed patient were lower for the omeprazole group ($US189.60) than for the ranitidine/metoclopramide group ($US319.28). The incremental cost of an additional cure with omeprazole compared with ranitidine/metoclopramide was $US24.05. The overall average cost per symptom-free day was lower in the omeprazole group ($US7.88) than in the ranitidine/metoclopramide group ($US10.81). The incremental cost to obtain an additional symptom-free day with omeprazole, compared with ranitidine/metoclopramide, was $US1.41. In conclusion, superior efficacy at comparable cost is achieved by omeprazole compared with ranitidine/metoclopramide in the treatment of patients with severe erosive oesophagitis.

Cost and quality effects of treating erosive oesophagitis. A re-evaluation

The objective of this study was to re-evaluate the clinical and economic effects of common therapies for erosive oesophagitis in the light of a newly approved treatment regimen. A previously constructed 7-month community practice decision analytical model was revised to include the latest published data on efficacy and symptomatic outcomes. The original results of phase I therapy (antacids plus dietary, sleeping and lifestyle changes) alone or combined with ranitidine 150mg bid or omeprazole 20mg od were reassessed by adding new clinical data on the efficacy of and symptomatic response to ranitidine 150mg qid. The same payment data used in the first analysis were applied here as well, with the addition of the US price of ranitidine 150mg qid. The study perspective was that of the payer or insurer. Omeprazole-based therapy remained a dominant strategy for symptomatic care during the 7-month model. It was 14% less costly per patient, led to 23% fewer symptomatic months, and had 21% lower cost per symptom-free month than ranitidine 150mg qid, the next best alternative. Evolving treatment strategies necessitate rapid assessment and reassessment so that clinical practice can remain current, patients can be assured of the best quality, and insurers can be aware of treatment cost and budgetary impact given limited resources in all countries. Only by consistent and continuous re-evaluation of new or changing medical interventions can clinicians and insurers adapt patient management to new scientifically derived results. This is the best manner by which to meet patients' care needs and the clinical needs of practitioners, as well as the financial needs of payers.

[Comparison of the cost-efficacy ratio of omeprazole and ranitidine in the treatment of reflux esophagitis]

OBJECTIVE

The objective of this study was to compare the cost of achieving a unit of clinical success for treatment of reflux oesophagitis with either ranitidine or omeprazole.

METHODS

After randomisation 430 patients with reflux oesophagitis (grade 2 or 3) were assigned to receive omeprazole 20 mg or ranitidine 150 b.i.d. for 8 weeks. Patients were given diary cards to assess their symptoms every day, and record every two weeks a life satisfaction index. Patients were seen after 4 and 8 weeks for symptoms assessment and repeat endoscopy at 8 weeks. The perspective of the analysis was that of the payer. The costs of medical care were based in French drug costs currently advertised, payment for physician and actual mean payment for upper GI endoscopy.

RESULTS

The healing rates at 8 weeks in the omeprazole group and the ranitidine group were 93 and 67.5% respectively. After 8 weeks of treatment, life satisfaction was good in 81 and 53.6% and the relief of pain was 86,6 and 69,5% respectively. For each effectiveness criteria, omeprazole was more cost effective than ranitidine: cost per healed patient (2,338 F vs 2,744 F), cost per asymptomatic patient (2,510 F vs 2,964 F), cost per patient with a good or very good life satisfaction index (2,687 F vs 3,456 F). This advantage remained independent of the oesophagitis initial severity. The sensitivity analysis showed that the results were unsensitive to the variations of the efficacy variables in their confidence interval.

CONCLUSIONS

This cost-effectiveness analysis suggests that in the treatment of reflux oesophagitis, the strategy with the more effective treatment is more cost-effective.

Adjusting dosage intervals of intermittent intravenous ranitidine according to creatinine clearance: a cost-minimization analysis

To provide effective ranitidine therapy at the lowest possible cost to institutions and patients, the main study objectives were to develop a dosage intervention strategy for intermittent intravenous ranitidine and to document the resultant cost savings through cost-minimization analysis. During a 6-week baseline phase, a pharmacy resident prospectively monitored all patients in the intensive care unit receiving intravenous ranitidine and evaluated appropriateness of dose according to creatinine clearance. Staff pharmacists collected identical data during the 6-week intervention phase but also made recommendations for dosage interval adjustment. In patients with creatinine clearance rates less than 50 mL per minute, the mean number of doses per patient treatment-day was reduced from 2.33 +/- 0.81 during baseline phase to 1.56 +/- 0.70 during intervention phase (P < 0.001). The hospital cost per patient treatment-day was decreased by 33%, from $5.29 +/- 1.83 to $3.54 +/- 1.59 (P < 0.001). Thus a program of prospective monitoring and verbal interventions by pharmacists effectively reduced the number of inappropriate ranitidine doses and hospital cost.

Optimal therapy for stress gastritis

OBJECTIVE

The authors compared the results of sucralfate versus H2 blocker +/- antacid as prophylaxis for stress ulceration in an intensive care unit patient population.

SUMMARY BACKGROUND DATA

Stress ulceration carries high morbidity and mortality for the patient who is critically ill. Gastric acid neutralization is an effective prophylaxis. The impact of increased gastric colonization with bacterial pathogens on nosocomial pneumonia after acid neutralization is unclear. The efficacy of sucralfate prophylaxis for stress ulceration and its the effect on the nosocomial pneumonia rate is controversial. The financial implications of sucralfate prophylaxis versus H2 blocker-based acid neutralization therapy has not been studied.

METHODS

Ninety-eight injured patients who were critically ill and who required intubation and intensive care unit (ICU) support for at least 72 hours without gastric feeding were randomized and received either maximal H2 blocker infusion therapy (continuous infusion of ranitidine at 0.25 mg/kg/hr after a loading dose of 0.5 mg/kg) plus antacids (for persistent pH < 4) or sucralfate (1 g every 6 hours via nasogastric tube) for stress ulcer prophylaxis. Efficacy in preventing stress ulcer complications was determined. The impact of each therapeutic approach on development of nosocomial pneumonia was evaluated. The charges/cost for each approach was analyzed.

RESULTS

Heme-positive gastric aspirates occurred in 99% of the patients, whereas 12 (7 in the H2 blocker group and 5 in the sucralfate group) were grossly positive for blood. However, only one from each group required transfusion, and one in the H2 blocker group required operation. Gastric colonization preceded tracheobronchial colonization in five patients in the H2 blocker group and one patient in the sucralfate group; simultaneous gastric/oropharyngeal colonization preceded positive tracheobronchial growth in six patients who received H2 blocker and one patient who received sucralfate. The overall pneumonia rate was 27.5% in the H2 blocker group and 20.8% in the sucralfate group (p = 0.48). Days on ventilator were 13.5 versus 9.1, (p = 0.06), ICU lengths of stay were 14.7 versus 10.2 (p = 0.06), and hospital lengths of stay were 27.8 versus 20.0 (p = 0.029) for the H2 blocker group and sucralfate group, respectively. Based on current charges and protocols for optimal H2 blocker and sucralfate prophylaxis, use of sucralfate rather than H2 blockers would decrease the annual cost by more than $30,000 per bed.

CONCLUSIONS

Sucralfate is as efficacious as maximal H2 blocker therapy for stress ulceration prophylaxis, and may have a beneficial effect on the incidence of nosocomial pneumonia. Sucralfate has a major reduction on nursing requirements for stress ulcer prophylaxis and would save approximately $30,000 per ICU bed per year in patient charges.

Ranitidine: a pharmacoeconomic evaluation of its use in acid-related disorders

Ranitidine is a histamine H 2-receptor antagonist which, on the basis of its well established tolerability and efficacy profile, has been widely prescribed for the treatment of ulcer disease and mild to moderate reflux oesophagitis. However, the advent of more powerful gastric acid inhibitors (e.g. acid pump inhibitors) and the realisation of the role of Helicobactor pylori infection in duodenal ulcer disease could have considerable clinical and economic implications for the use of ranitidine (and other H 2-receptor antagonists). Simulation modelling studies based on current pricing policies in Europe predict that ranitidine-based treatment will be less cost effective than omeprazole in the short term healing of duodenal ulcer and reflux oesophagitis disease. During longer term treatment, omeprazole is expected to be the dominating strategy over ranitidine-based therapy in Europe and the US. However, the inherent limitations of modelling studies reinforce the need for randomised prospective trials, preferably conducted in a general practice setting and including a quality-of-life analysis. Of the currently accepted approaches for the long term management of recurrent duodenal ulcer disease, daily maintenance therapy with ranitidine has been shown to be more cost effective than intermittent treatment for up to 2 years in the US. The annual cost of providing continuous maintenance therapy with ranitidine 150 mg/day is higher than with cimetidine 400 mg/day, although the extra benefits include a reduced risk of pain and discomfort from an expected lower rate of ulcer recurrence with ranitidine. Simultaneous ulcer healing and eradication of H. pylori markedly reduces relapse rates and is likely to become the management strategy of choice in H. pylori-positive patients, particularly with the advent of more convenient, well tolerated and effective regimens. Moreover, widespread clinical acceptance of H. pylori eradication may yield substantial cost savings to society by reducing the overall need for long term antisecretory therapy. Nonetheless, maintenance therapy with histamine H 2-receptor antagonists remains indicated for patients at high risk of ulcer recurrence who are poorly responsive to or cannot tolerate H. pylori eradication regimens. In summary, the proven efficacy and tolerability of ranitidine will ensure its continued use in the treatment of many patients with duodenal ulcer and mild to moderate reflux oesophagitis. However, there is increasing clinical and economic data favouring the selection of omeprazole in patients with more severe symptoms of these diseases.(ABSTRACT TRUNCATED AT 400 WORDS)

A pharmacoeconomic analysis of IV H2-receptor antagonist use in 40 hospitals

The objectives of this study were to determine (1) the expenditures of hospitals for IV histamine2-receptor antagonists (H2-RA), and (2) the cost savings that might be realized if only a single IV H2-RA was purchased for use. Forty hospitals provided data about purchase prices for each IV H2-RA dosage form purchased (cimetidine, ranitidine, and famotidine), the number of each dosage form used during the 12-month study period, purchase price and extent of usage for supplies, labor costs for preparing and administering IV H2-RAs, and IV H2-RA dosage schedules. The study showed that most hospitals were spending more money for IV H2-RAs than necessary given the pricing structures of the three products available to them at the time of this study. Also, that significant cost savings could be realized if a single H2-RA was used exclusively.

Long-term consequences with regard to clinical outcome and cost-effectiveness of episodic treatment with omeprazole or ranitidine for healing of duodenal ulcer

The clinical outcome and cost-effectiveness of episodic treatment of duodenal ulcer with omeprazole and ranitidine were evaluated over a 5-year period. The analysis was based on data from published clinical trials comparing healing rates obtained with omeprazole and with ranitidine, as well as on data from the literature on ulcer recurrence and other clinical events. Patients with an active duodenal ulcer were treated until healed or for a maximum of 24 weeks. Maintenance therapy was instituted in patients with ulcers that were very slow to heal and in patients with frequent relapses after cessation of treatment. Patients who experienced frequent relapses while receiving maintenance therapy, and those whose ulcer had not healed after 24 weeks of continuous treatment, were defined as candidates for surgery. A statistical model was set up and a random number generator used to generate a sequence of clinical events, month by month, over a 5-year period for each patient in a large cohort. Episodic treatment with omeprazole was shown to be more effective in avoiding maintenance treatment and surgery when compared with episodic treatment with ranitidine. Patients who received episodic treatment with omeprazole also spent more time in remission from disease. Using current Swedish cost data, it was found that episodic treatment with omeprazole was more cost-effective than episodic treatment with ranitidine.

Economic analysis of alternative treatments for persistent gastro-oesophageal reflux disease

The economic evaluation of new medicines is increasingly important for pricing, registration and selection for use. A decision-analytic strategy was performed to assess the economic impact of antacids alone (phase I therapy), and in combination with either omeprazole, 20 mg once daily, or ranitidine, 150 mg twice daily, for patients with persistent, symptomatic gastro-oesophageal reflux disease of grade II or more (Savary-Miller classification). Data were obtained from published literature, an expert panel of gastroenterologists and actual payments by a private insurer in the USA. Over the 7-month period of the analysis, omeprazole reduced both symptoms and overall costs when compared with ranitidine or antacids. Consequently, the cost per symptom-free month was 43% lower with omeprazole than with ranitidine. Thus, omeprazole should be considered as the initial therapeutic approach for patients in whom phase I therapy fails.

Economic evaluation of new medical technology

Safety and efficacy are not the only parameters of interest for choice of medical technology--costs play an increasingly important role. There is a growing interest in 'value for money', which can be assessed by economic evaluation comparing the costs and consequences of alternative courses of action. A number of different economic evaluation methods may be used: cost-minimization (looking only at costs with no consideration of consequences); cost-effectiveness (in which a unidimensional clinical outcome is assessed, for example, life-years gained); cost-utility (measuring multidimensional outcomes, for example quantity and quality of life); and cost-benefit (where outcome is considered in monetary terms). A Swedish cost-of-illness study showed that the direct health care costs increased and the indirect cost (in terms of production loss) associated with treatment of peptic ulcer fell following the introduction of H2-receptor antagonists. In a study of reflux oesophagitis, omeprazole was shown to be more cost-effective than ranitidine. With omeprazole, the costs were lower and the effectiveness better than with the H2-receptor antagonist.

[Evaluation of the cost of maintenance therapy (6 months) with 150 mg ranitidine vs 20 mg omeprazole vs 20 mg omeprazole every other day in duodenal ulcer]

Prevention of ulcer relapse and of its complications is a problem which remains to be solved. Our study involved 250 patients, with healed duodenal ulcer. We evaluated efficacy and costs of three different maintenance therapies: ranitidine 150 mg/day, omeprazole 20 mg/day every other day and omeprazole 20 mg/day. Six months later, we found the incidence of relapse to be 24.4% (32/131) in the once-a-day ranitidine group, 19.7% (13/66) in the day every-other-day omeprazole group, and 3.8% (2/53) in the once-a-day omeprazole group. Further, we evaluated costs relative to relapsing patients, and total costs for each treatment group. From these data, we conclude that personalized maintenance therapy with omeprazole is the most cost-effective: a dosage of 20 mg/day is extremely effective in maintaining remission, and is therefore most indicated in patients at risk; omeprazole 20 mg/day every-other-day affords better compliance, lower costs and fewer relapses with respect to standard H2-antagonist dosages.