Inahta briefs

Issue 2010/056
Cyclooxygenase-2 Selective Non-Steroidal Anti-Inflammatory
Drugs (Etodolac, Meloxicam, Celecoxib, Rofecoxib, Etoricoxib,
Valdecoxib and Lumiracoxib) for Osteoarthritis and Rheumatoid
Arthritis: A Systematic Review and Economic Evaluation

NETSCC, HTA, NIHR Evaluation and Trials Coordinating Centre
Alpha House, University of Southampton Science Park, Southampton, SO16 7NS, United Kingdom;
Reference Volume 12.11. ISSN 1366-5278.
To review the clinical and cost effectiveness of cyclo - This report summarizes the best available evidence and oxygenase-2 (COX-2) selective nonsteroidal antiinflam- discusses its implications, but does not make recom- matory drugs (NSAIDs) for osteoarthritis (OA) and mendations about policy or clinical care.
Conclusions and results
Systematic reviews of randomized controlled trials and The COX-2 selective NSAIDs examined in this report a model-based economic evaluation were undertaken. (ie, etodolac, meloxicam, celecoxib, rofecoxib, valde- Electronic databases were searched up to November coxib, etoricoxib, and lumiracoxib) were found to be 2003. Industry submissions to the National Institute similar to nonselective NSAIDs for the symptomatic for Health and Clinical Excellence in 2003 were also re- relief of RA and OA and to provide superior gastrointes- viewed. Meta-analyses were undertaken for each COX-2 tinal (GI) tolerability (most evidence is in patients with selective NSAID compared with placebo and nonselec- OA). Although COX-2 selective NSAIDs offer protec- tion against serious GI events compared to nonselective NSAIDs, the amount of evidence for this protective ef- Further research/reviews required
fect varied considerably across individual drugs. The With reduced costs of PPIs, future primary research volume of trial evidence with regard to cardiovascular needs to compare the effectiveness and cost effective- safety also varied substantially between COX-2 selec- ness of COX-2 selective NSAIDs relative to nonselective tive NSAIDs. Increased risk of myocardial infarction NSAIDs with a PPI. Direct comparisons of different (MI) compared to nonselective NSAIDs was observed COX-2 selective NSAIDs, using equivalent doses that among those drugs with greater volume of evidence in compare GI and MI risk are needed. Pragmatic studies terms of exposure in patient-years. Subgroup analyses of that include a wider range of people, including the older clinical and complicated upper GI events and MI events age groups with a greater burden of arthritis, are also related to aspirin use, steroid use, prior GI history, and Helicobacter pylori status were based on relatively small numbers and were inconclusive. Economic modeling shows a wide range of possible costs per quality-adjusted life year (QALY) gained in patients with OA and RA. Costs per QALY varied if individual drugs were used in standard- or high-risk patients, the choice of nonselective NSAID comparator, and whether NSAID was com- bined with a proton pump inhibitor (PPI). When the model was run using ibuprofen or diclofenac combined with a PPI as the comparator, the results changed sub- stantially, with the COX-2 selective NSAIDs looking generally unattractive from a cost-effectiveness stand- point. See Executive Summary link at Written by Dr Yen-Fu Chen, University of Birmingham, NETSCC, United Kingdom


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