Health economics of topical NSAIDs
Clinical bottom line
The use of topical NSAIDs in patients in whom it is appropriate probably costs less than using oral NSAIDs. Although the acquisition cost of topical NSAIDs tends to be higher than that of generic NSAIDs, lower costs of adverse events results in savings for the whole health economy.
Background
Topical NSAID use is sometimes questioned because they cost more than generic oral NSAIDs. But oral NSAIDs are associated with significant adverse events (gastrointestinal, heart failure, and renal failure). Topical NSAIDs have much lower plasma concentrations, and are not associated with higher rates of adverse events, or at any rate of gastrointestinal adverse events.
Survey
Bandolier sought studies of the health economics of topical NSAID use by searching PubMed. None were found in the last five years (1999 on), and only two previously.
Results
The two studies found are summarised in the Table. Both compared a topical NSAID with an oral NSAID (generic ibuprofen), and examined costs over one month and three months. Both used literature information about rate and costs of upper gastrointestinal adverse events. Neither considered any additional benefits relating to lower rates of cardiovascular or renal adverse events, or anaemia associated with oral NSAID use.
Both studies concluded that total costs of topical NSAID were lower than those of oral NSAIDs, and for the same reason, because of lower adverse event rates. Higher acquisition costs for topical NSAID were offset by lower adverse event costs.
Table: Summary of health economic studies on topical NSAIDs
| Peacock & Rapier. Br J Med Econ 1993 6: 135-142 | Cost-effectiveness study of one month treatment of 1,000 patients with oral ibuprofen, Arthrotec, or topical felbinac. Study included drug costs and cost of adverse events | Cost per 1,000 patients was: oral ibuprofen £41,408 oral Arthrotec £17,924 topical felbinac £7,319 |
| McKell & Steward. Br J Med Econ 1994 7: 137-146 | Cost minimisation analysis comparing oral ibuprofen (1200 mg daily) with topical piroxicam (three times daily) in mild OA. | Cost of three months' treatment: oral ibuprofen £89 topical piroxicam £55 |
Comment
There is very considerable evidence that oral NSAIDs produce significant upper gastrointestinal adverse events because of gastroduodenal ulceration, and, in some cases, bleeding. These require hospital treatment or prophylaxis with proton pump inhibitors to prevent these adverse events. Gastrointestinal adverse events are known not to be a feature of topical NSAID use.
That topical NSAID use would be cheaper than oral NSAID use, in patients for whom topical NSAIDs would be appropriate, makes sense. The arguments are similar to those made for the cyclooxygenase-2 inhibitors, and recent research has shown that overall costs of these newer drugs is no more costly than oral NSAIDs [1], again because higher acquisition costs are offset by savings elsewhere.
Reference
- C Harley, S Wagner. Persistence with COX-2 inhibitors in managed care: an analysis of claims data. Managed care Interface 2003 October 38-45.