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Pharmacoeconomics of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

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Summary

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for the relief of the symptoms of osteoarthritis (OA), rheumatoid arthritis (RA), sprains and strains, sports injuries and menstrual disorders, and have a small role in the management of patent ductus arteriosus in the neonate.

In patients with RA, symptom relief through use of NSAIDs is firmly established, although it remains unclear whether they influence the course and outcome of the disease. For the average patient with RA taking NSAIDs, the attributable risk of hospitalisation with gastrointestinal problems related to NSAIDs is 1.3 to 1.6% annually and risk of death is 0.15%. Associations of therapy with risk are greatest with age, corticosteroid use and previous NSAID-related gastrointestinal adverse effects, and less marked with disability and high NSAID dose. These are important data in attempting to balance risk of therapy with clinical efficacy in an individual patient, and assessing the cost-effectiveness of prophylaxis.

Although half of all NSAID consumption is for control of pain associated with degenerative conditions, their superiority over simple analgesics in osteoarthritis is poorly documented. This finding supports the use of the simple analgesic paracetamol (acetaminophen) as the preferred therapy of osteoarthritis, especially when its lower cost and low incidence of adverse effects are taken into consideration.

Consistent differences in clinical effectiveness of individual NSAIDs have not been demonstrated, although unpredictable interpatient variation in response to individual agents is of considerable clinical importance, and a more expensive NSAID may prove cost effective for some patients. Cost effectiveness can be improved by a self-adjusted dosage regime which also leads to lower overall drug consumption. The adverse gastrointestinal effects of these drugs account for about 30% of the overall cost of arthritis treatment, and although studies to date have been too limited to assess the relative risk of gastrointestinal toxicity of the different NSAIDs reliably, ibuprofen appears to be one of the least hazardous, and azapropazone one of the most hazardous. Although the effectiveness of prophylaxis with H2-antagonists and with prostaglandin Ei analogues (prostaglandin-E1 analogues has been established, estimates of cost-benefit ratios are widely divergent. To establish the most cost-effective therapy with NSAIDs, more data are required to establish multivariable risk profiles for identification of patients at particular risk, the optimal drug, and its optimal dosage and duration of treatment. A more cost-effective use of NSAIDs could be achieved by a more thorough clinical assessment of efficacy in an individual patient which would lead to a lower overall use but greater therapeutic benefit.

There is only limited evidence for the efficacy of NSAIDs in acute musculoskeletal disorders such as strains, sprains or sports injuries. There is no clear evidence of superiority among drugs, and no studies have yet examined the pharmacoeconomic aspects of their use compared with other effective treatment options.

Although satisfactory cost-effectiveness data are not available for the use of NSAIDs in management of dysmenorrhoea, they are clinically effective (particularly ibuprofen, naproxen and mefenamic acid), and serious adverse effects are rare because of the short treatment periods. NSAIDs have limited efficacy in reducing blood loss in menorrhagia, and there is no clear evidence of superiority among agents. Pharmacoeconomic studies to support their cost effectiveness over other treatment options are not available.

Indomethacin has a role as a preferred and cost-effective treatment for patent ductus arteriosus in the neonate, with surgery being used when drug therapy fails.

Only limited data on the cost effectiveness of NSAIDs are available, despite their wide use. In part, this reflects the primarily clinical assessment of the effectiveness of treatments. The development of standardised and well validated assessment instruments is required. Such data as are available are sometimes from poorly designed studies. Future studies must include randomisation of treatments and blinding of participants to therapies wherever possible.

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  1. Wolfson Unit of Clinical Pharmacology and Regional Drug and Therapeutics Centre, University of Newcastle Upon Tyne, Claremont Place, Newcastle Upon Tyne, NE1 7RU, England

    Hilary A. Wynne & Mark Campbell

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Wynne, H.A., Campbell, M. Pharmacoeconomics of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). Pharmacoeconomics 3, 107–123 (1993). https://doi.org/10.2165/00019053-199303020-00004

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