A systematic review of the economic evaluations of the different proton pump inhibitors (PPIs) marketed in Spain
تعليق: بحث ممتاز.--احمد شوقي محمدين 20:31، 22 أكتوبر 2016 (ت ع م)
A systematic review of the economic evaluations of the different proton pump inhibitors (PPIs) marketed in Spain
December 2006
Agència d’Avaluació de Tecnologies i Recerca Mèdiques (Medical Research and Technology Evaluation Agency)
Research team
José Luis Pinto Prades, Doctor of Economy, MSc in Health Economics (University of York), Professor of Economics, Pompeu Fabra University.
Marco Barbieri, Economics Graduate, MSc in Health Economics (University of York), Associate Professor, Pompeu Fabra University.
M. Gabriella Giunta, Doctor of Health Economics (University of Catania), MSc in Health Economics (University of York), Researcher at the Centre for Reviews and Dissemination (CRD), University of York.
Acknowledgements: we would like to thank doctors Javier Pérez Gisbert (La Princesa University Hospital, Madrid) and Xavier Calvet (Parc Taulí University Institute, Sabadell Hospital) for their comments on this manuscript. The content of this report is, of course, the exclusive responsibility of its authors.
EXECUTIVE SUMMARY
محتويات
Background[عدل]
Gastroesophageal reflux disease (GERD) is one of the (or the) most common pathologies of the western world. Clinically it manifests as pyrosis or acid regurgitation that increases after meals and improves after taking antisecretory drugs or antacids. It can also present with belching, epigastric pain, postprandial fullness, nauseas, hiccups, dysphagia, odynophagia, anaemia, pharyngeal problems, respiratory disturbances or thoracic pain.
The most effective treatment for GERD is the pharmacological inhibition of acid secretion. The H2-antagonists, like ranitidine, are useful in relieving the symptoms in mild forms of the disease, but are less effective in the treatment of reflux esophagitis. Proton pump inhibitors (PPIs) are more effective both in relieving the symptoms, as well as in curing the esophagitis and, in addition, do not lead to tolerance in prolonged treatments. At present, five proton pump inhibitors are marketed in Spain: omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole.
Objectives[عدل]
• To review the literature of economic evaluations that compare different PPIs to each other.
• To examine the sources of the relevant economic evaluations, thereby distinguishing between studies published in international or national journals (peer-reviewed or not), grey literature and other possible sources.
• To assess the quality and the limitations of the evidence provided in the studies reviewed, with regard both to the results and to the costs, in accordance with the most widely accepted international recommendations on the quality of clinical and economic evidence.
• To write a detailed report on the articles reviewed, emphasising the methodological aspects of each study, with the aim of proposing recommendations for the efficient use of public resources in the context of the funder of the Catalan public health care system (CatSalut).
Methods[عدل]
An exhaustive review of the pharmacoeconomic studies was undertaken in which various PPIs were compared to each other on the basis of a search of the entire bibliography available and other possible sources. A detailed specification of the search criteria is provided in the report.
Results[عدل]
The comparative effectiveness of the PPIs[عدل]
Many authors are of the opinion that all the PPIs are equally effective for all indications. Accordingly, many authors and certain clinical practice guidelines consider that the use of omeprazole should be the first choice, since it is the cheapest PPI and its effectiveness is very similar (or equal) to that of the other PPIs.
Nevertheless, there is some evidence available to suggest that, for certain indications, esomeprazole is more effective than the other PPIs. Some authors believe that the aforementioned greater effectiveness is due exclusively to the different doses used. Those authors point out that when esomeprazole and omeprazole have been compared using equal doses, esomeprazole has not proven to be more effective. Other authors consider that, although esomeprazole is slightly more effective than omeprazole, the greater effectiveness is very small and is clinically irrelevant. In any case, in standard doses (esomeprazole 40 mg and omeprazole 40 mg), esomeprazole has proven to be more effective than omeprazole in the treatment of severe gastroesophageal reflux. The said greater effectiveness is produced both when assessed through the cure or relief of symptoms as well as through endoscopic control.
The comparative cost-effectiveness of the different PPIs[عدل]
• The economic evaluation studies analysed were conducted in contexts that differ from the current context in Spain and, therefore, many of the conclusions in the section regarding treatment costs need to be adapted to the current situation. In particular, those studies used similar costs for the different PPIs, whereas at present there is a big price difference between omeprazole and the other PPIs. In some cases own estimates were made using the data provided in the evaluated studies and the current costs of the PPIs in Spain. Likewise, the clinical evidence on which many of the economic evaluations are based should be reviewed, since they use data based on indirect comparisons with placebo whereas, after the publication of the study, evidence appeared of direct comparisons between drugs. In other cases, the evidence on which they are based is, today still, the best available.
• In view of the lack of evidence of a greater effectiveness between omeprazole, lansoprazole, pantoprazole and rabeprazole, the studies that should be used to compare those PPIs to each other are the cost minimisation studies, and not the cost-effectiveness studies. Three cost minimisation studies were evaluated; because of the aforementioned price differences their relevance to the current situation was limited. Whenever it was possible to make own estimates on the basis of the data provided by the authors, it was obvious that omeprazole is the PPI with the lowest costs. That is true is spite of the fact that, as two studies show, the actual dose of omeprazole tends to be higher than the recommended daily dose, thus increasing the cost of the use of omeprazole. Nevertheless, omeprazole continues to be associated with lower costs for a same effectiveness.
• Several cost-effectiveness studies compare esomeprazole to other PPIs. The published studies conclude that esomeprazole is more effective and cheaper than omeprazole. Although the first conclusion (greater effectiveness of esomeprazole) could be accepted, the same is not true for the second conclusion (esomeprazole being cheaper), considering the current prices of those two drugs. Again, a replica was made of some of those models using the current prices of both drugs and the result is that omeprazole is clearly cheaper. Therefore, esomeprazole is more effective, but more expensive.
• There are no cost-utility or cost-benefit studies that make it possible to judge, in a more or less objective way, whether the difference in the effectiveness of esomeprazole can justify the greater difference in costs. Some preliminary estimates were made in this report, based on utilities found in the literature, obtaining a cost that ranges between €40,000 and €150,000 per Quality Adjusted Life Year (QALY). The said cost per QALY is much higher than the cost suggested in the literature. Likewise, the only study of willingness-to-pay to avoid GERD suggests that the additional cost of treating a patient with esomeprazole is too high. These results suggest that the benefit of esomeprazole is small in relation to its cost when compared to omeprazole.
Conclusions[عدل]
• Omeprazole is the PPI with the best pharmacoeconomic profile and should be used as the first choice.
• No arguments were found, from the perspective of the cost-effectiveness analysis, for the use of a PPI other than omeprazole. In most of the indications, this conclusion is due to the fact that there is no evidence to suggest that the more expensive PPIs are more effective.
• The only case that may lead to certain doubts is the treatment of severe GERD with esomeprazole which, when used in standard doses, showed this PPI to be slightly superior to the rest, including omeprazole. This conclusion is preliminary and needs to be confirmed through empirical studies. Likewise, analyses of subgroups need to be carried out according to the severity of the GERD.
