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July 4, 1990, Vol 264, No. 1 >
ARTICLE | July 4, 1990

Cost-effectiveness of Misoprostol for Prophylaxis Against Nonsteroidal Anti-inflammatory Drug—Induced Gastrointestinal Tract Bleeding FREE

Jonathan T. Edelson, MD; Anna N. A. Tosteson, ScD; Paul Sax, MD
[+] Author Affiliations

Reprint requests to Medical Decision Resources Inc, 459 Washington St, Suite 3, Brookline, MA 02146 (Dr Edelson).


JAMA. 1990;264(1):41-47. doi:10.1001/jama.1990.03450010045028
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Article
References

Patients who take nonsteroidal anti-inflammatory drugs (NSAIDs) are at increased risk of upper gastrointestinal tract bleeding, which may be prevented with prophylactic prescription of misoprostol. Using data from the literature, we estimated rates of gastrointestinal tract bleeding in NSAID users, direct medical costs, years of life lost, and cost-effectiveness of a 1-year course of misoprostol in three clinical populations of NSAID users: all users, users aged 60 years or older, and users with rheumatoid arthritis. The incremental cost-effectiveness ratios for misoprostol as primary prevention were $667 400 per year of life saved for all NSAID users; $186 700 per year of life saved for users aged 60 years or older; and $95 600 per year of life saved for users with rheumatoid arthritis. Misoprostol as secondary prevention for those who continued to take NSAIDs despite having had an episode of gastrointestinal tract bleeding in the previous year was associated with incremental cost-effectiveness ratios less than $40 000 per year of life saved in all patient groups. We conclude that misoprostol is costly as primary prevention for NSAID-induced gastrointestinal tract bleeding in the groups examined but may be cost-effective as secondary prevention in patients with a proved history of gastrointestinal tract bleeding.

(JAMA. 1990;264:41-47)

REFERENCES

1 +
Langman MJS.  Ulcer complications and nonsteroidal anti-inflammatory drugs . Am J Med. 1988;; 84( (suppl 2A) ):15-18.
2 +
Carson JL, Strom BL, Soper KA, et al.  The association of nonsteroidal anti-inflammatory drugs with upper gastrointestinal bleeding . Arch Intern Med. 1987;;147:85-88.
3 +
Bartle WR, Gupta AK, Lazor J.  Nonsteroidal anti-inflammatory drugs and gastrointestinal bleeding . Arch Intern Med. 1986;;146:2365-2367.
4 +
Carson JL.  A case study: nonsteroidal antiinflammatory drugs and gastrointestinal bleeding . J Rheumatol. 1988;;15( (suppl 17) ):24-27.
5 +
Fries JF, Miller SR, Spitz PW, et al.  Toward an epidemiology of gastropathy with nonsteroidal antiinflammatory drug use . Gastroenterology . 1989;; 96:647-655.
6 +
Langman MJS.  Epidemiologic evidence on the association between peptic ulceration and antiinflammatory drug use . Gastroenterology . 1989;;96: 640-646.
7 +
Roth SH, Bennett RE.  Nonsteroidal anti-inflammatory drug gastropathy . Arch Intern Med. 1987;;147:2093-2100.
8 +
Soll AH, Kurata J, McGuigan JE.  Ulcers, nonsteroidal antiinflammatory drugs, and related matters . Gastroenterology . 1989;;96:561-568.
9 +
Cockel R.  NSAIDs: should every prescription carry a government health warning? Gut. 1987;;28: 515-518.
10 +
Griffin MR, Ray WA, Schaffner W.  Nonsteroidal anti-inflammatory drug use and death from peptic ulcer in elderly persons . Ann Intern Med. 1988;;109:359-363.
11 +
Henry DA, Johnston A, Dobson A, Duggan J.  Fatal peptic ulcer complications and the use of nonsteroidal anti-inflammatory drugs, aspirin, and corticosteroids . BMJ. 1987;;295:1227-1229.
12 +
Jick SS, Perera DR, Walker AM, Jick H.  Nonsteroidal anti-inflammatory drugs and hospital admission for perforated peptic ulcer . Lancet . 1987;;2:380-382.
13 +
Graham DY.  Prevention of gastrointestinal injury induced by chronic nonsteroidal antiinflammatory drug therapy . Gastroenterology . 1989;;96:675-681.
14 +
Bloom BS.  Direct medical costs of disease and gastrointestinal side effects during treatment of arthritis . Am J Med. 1988;;84( (suppl 2A) ):20-24.
15 +
Graham DY, Agrawal NM, Roth SH.  Prevention of NSAID-induced gastric ulcer with misoprostol: multicentre, double-blind, placebo-controlled trial . Lancet . 1988;;2:1277-1280.
16 +
Davies J, Collins AJ, Dixon ASJ.  The influence of cimetidine on peptic ulcer in patients with arthritis taking anti-inflammatory drugs . Br J Rheumatol. 1986;;25:54-58.
17 +
Ehsanullah RSB, Page MC, Tildesley G, Wood JR.  Prevention of gastroduodenal damage induced by non-steroidal anti-inflammatory drugs: controlled trial of ranitidine . BMJ . 1988;;297:1017-1021.
18 +
Bloom BS.  Risk and cost of gastrointestinal side effects associated with nonsteroidal anti-inflammatory drugs . Arch Intern Med. 1989;;149: 1019-1022.
19 +
McCarthy DM.  Nonsteroidal antiinflammatory drug—induced ulcers: management by traditional therapies . Gastroenterology . 1989;;96:662-674.
20 +
Roth SH, Bennett RE, Mitchell CS, Hartman RJ.  Cimetidine therapy in nonsteroidal anti-inflammatory drug gastropathy . Arch Intern Med. 1987;;147:1798-1801.
21 +
Lanza FL, Aspinall RL, Swabb EA, et al.  Double-blind, placebo-controlled endoscopic comparison of the mucosal protective effects of misoprostol versus cimetidine on tolmentin-induced mucosal injury to the stomach and duodenum . Gastroenterology. 1988;;95:289-294.
22 +
Armstrong CP, Blower AL.  Non-steroidal anti-inflammatory drugs and life threatening complications of peptic ulceration . Gut. 1987;;28:527-532.
23 +
Caldwell JR, Roth SH, Wu WC, et al.  Sucralfate treatment of nonsteroidal anti-inflammatory drug-induced gastrointestinal symptoms and mucosal damage . Am J Med. 1987;;83( (suppl 3B) ):74-82.
24 +
Hillman AL, Bloom BS.  Economic effects of prophylactic use of misoprostol to prevent gastric ulcer in patients taking nonsteroidal anti-inflammatory drugs . Arch Intern Med. 1989;;149:2061-2065.
25 +
Weinstein MC, Stason WB.  Foundations of cost-effectiveness analysis for health and medical practices . N Engl J Med. 1977;;296:716-721.
26 +
Eisenberg JM.  Clinical economics: a guide to the economic analysis of clinical practices . JAMA . 1989;;262:2879-2897.
27 +
Hollenberg J. SMLTREE . Roslyn, NY: 1989;. Computer software.
28 +
Kurata JH.  Ulcer epidemiology: an overview and proposed research framework . Gastroenterology . 1989;;96:569-580.
29 +
National Health Survey. Detailed Diagnoses and Procedures for Patients Discharged From Short-stay Hospitals, United States, 1986 . Hyattsville, Md: National Center for Health Statistics; 1988;. Series 13, No. (95) .
30 +
Statistical Abstract of the United States 1988 . Washington, DC: Bureau of the Census; 1988;.
31 +
Kurata JH, Honda GD, Frankl H.  Hospitalization and mortality rates for peptic ulcers: a comparison of a large health maintenance organization and United States data . Gastroenterology . 1982;;83: 1008-1016.
32 +
Beard K, Walker AM, Perera DR, Jick H.  Nonsteroidal anti-inflammatory drugs and hospitalization for gastroesophageal bleeding in the elderly . Arch Intern Med. 1987;;147:1621-1623.
33 +
Bonnevie O.  The incidence of gastric ulcer in Copenhagen County . Scand J Gastroenterol. 1975;; 10:231-239.
34 +
Bonnevie O.  The incidence of duodenal ulcer in Copenhagen County . Scand J Gastroenterol. 1975;;10:385-393.
35 +
Coles LS, Fries JF, Kraines RG, Roth SH.  From experiment to experience: side effects of nonsteroidal anti-inflammatory drugs . Am J Med. 1983;;74:820-828.
36 +
Cucala M, Baurfeind P, Emde C, et al.  Is it wise to prescribe NSAIDs with modern gastroprotective agents? Scand J Rheumatol. 1987;;( (suppl 67) ):141-154.
37 +
Pounder R.  Silent peptic ulceration: deadly silence or golden silence? Gastroenterology . 1989;;96: 626-631.
38 +
Van Deventer GM, Elashoff JD, Reedy TJ, et al.  A randomized study of maintenance therapy with ranitidine to prevent the recurrence of duodenal ulcer . N Engl J Med. 1989;;320:1113-1119.
39 +
Lilienfeld AM, Lilienfeld DE. Foundations of Epidemiology . 2nd ed. New York, NY: Oxford University Press; 1980;.
40 +
Walt R, Katschininski B, Logan R, et al.  Rising frequency of ulcer perforation in elderly people in the United Kingdom . Lancet . 1986;;1:489-492.
41 +
Vital Statistics of the United States 1986: Mortality, Part A . Hyattsville, Md: National Center for Health Statistics; 1988;;2.
42 +
Committee on Safety of Medicines.  Non-steroidal anti-inflammatory drugs and serious gastrointestinal side-effects . BMJ . 1986;;292:614.
43 +
Mitchell DM, Spitz PW, Young DY, et al.  Survival, prognosis, and causes of death in rheumatoid arthritis . Arthritis Rheum. 1986;;29:706-714.
44 +
Symmons DPM.  Mortality in rheumatoid arthritis . Br J Rheumatol. 1988;;27( (suppl 1) ):44-54.
45 +
Willems JS, Sanders CR, Riddiough MA, et al.  Cost-effectiveness of vaccination against pneumococcal pneumonia . N Engl J Med. 1980;;303:553-559.
46 +
Edelson JT, Weinstein MC, Tosteson ANA, et al.  Long-term cost-effectiveness of various initial mono-therapies for mild to moderate hypertension . JAMA . 1990;;263:408-413.
47 +
Goldman L, Sia STB, Cook EF, et al.  Costs and effectiveness of routine therapy with long-term beta-adrenergic antagonists after acute myocardial infarction . N Engl J Med. 1988;;319:152-157.
48 +
Kinosian BP, Eisenberg JM.  Cutting into cholesterol . JAMA . 1988;;259:2249-2254.
49 +
Butt JH, Barthel JS, Moore RA.  Clinical spectrum of the upper gastrointestinal effects of nonsteroidal anti-inflammatory drugs . Am J Med. 1988;;84( (suppl 2A) ):5-14.
50 +
Beck JR, Pauker SG.  The Markov process in medical prognosis . Med Decis Making. 1983;;3:421-458.
51 +
Stason WB, Weinstein MC.  Allocation of resources to manage hypertension . N Engl J Med. 1977;;296:732-739.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Langman MJS.  Ulcer complications and nonsteroidal anti-inflammatory drugs . Am J Med. 1988;; 84( (suppl 2A) ):15-18.
2 +
Carson JL, Strom BL, Soper KA, et al.  The association of nonsteroidal anti-inflammatory drugs with upper gastrointestinal bleeding . Arch Intern Med. 1987;;147:85-88.
3 +
Bartle WR, Gupta AK, Lazor J.  Nonsteroidal anti-inflammatory drugs and gastrointestinal bleeding . Arch Intern Med. 1986;;146:2365-2367.
4 +
Carson JL.  A case study: nonsteroidal antiinflammatory drugs and gastrointestinal bleeding . J Rheumatol. 1988;;15( (suppl 17) ):24-27.
5 +
Fries JF, Miller SR, Spitz PW, et al.  Toward an epidemiology of gastropathy with nonsteroidal antiinflammatory drug use . Gastroenterology . 1989;; 96:647-655.
6 +
Langman MJS.  Epidemiologic evidence on the association between peptic ulceration and antiinflammatory drug use . Gastroenterology . 1989;;96: 640-646.
7 +
Roth SH, Bennett RE.  Nonsteroidal anti-inflammatory drug gastropathy . Arch Intern Med. 1987;;147:2093-2100.
8 +
Soll AH, Kurata J, McGuigan JE.  Ulcers, nonsteroidal antiinflammatory drugs, and related matters . Gastroenterology . 1989;;96:561-568.
9 +
Cockel R.  NSAIDs: should every prescription carry a government health warning? Gut. 1987;;28: 515-518.
10 +
Griffin MR, Ray WA, Schaffner W.  Nonsteroidal anti-inflammatory drug use and death from peptic ulcer in elderly persons . Ann Intern Med. 1988;;109:359-363.
11 +
Henry DA, Johnston A, Dobson A, Duggan J.  Fatal peptic ulcer complications and the use of nonsteroidal anti-inflammatory drugs, aspirin, and corticosteroids . BMJ. 1987;;295:1227-1229.
12 +
Jick SS, Perera DR, Walker AM, Jick H.  Nonsteroidal anti-inflammatory drugs and hospital admission for perforated peptic ulcer . Lancet . 1987;;2:380-382.
13 +
Graham DY.  Prevention of gastrointestinal injury induced by chronic nonsteroidal antiinflammatory drug therapy . Gastroenterology . 1989;;96:675-681.
14 +
Bloom BS.  Direct medical costs of disease and gastrointestinal side effects during treatment of arthritis . Am J Med. 1988;;84( (suppl 2A) ):20-24.
15 +
Graham DY, Agrawal NM, Roth SH.  Prevention of NSAID-induced gastric ulcer with misoprostol: multicentre, double-blind, placebo-controlled trial . Lancet . 1988;;2:1277-1280.
16 +
Davies J, Collins AJ, Dixon ASJ.  The influence of cimetidine on peptic ulcer in patients with arthritis taking anti-inflammatory drugs . Br J Rheumatol. 1986;;25:54-58.
17 +
Ehsanullah RSB, Page MC, Tildesley G, Wood JR.  Prevention of gastroduodenal damage induced by non-steroidal anti-inflammatory drugs: controlled trial of ranitidine . BMJ . 1988;;297:1017-1021.
18 +
Bloom BS.  Risk and cost of gastrointestinal side effects associated with nonsteroidal anti-inflammatory drugs . Arch Intern Med. 1989;;149: 1019-1022.
19 +
McCarthy DM.  Nonsteroidal antiinflammatory drug—induced ulcers: management by traditional therapies . Gastroenterology . 1989;;96:662-674.
20 +
Roth SH, Bennett RE, Mitchell CS, Hartman RJ.  Cimetidine therapy in nonsteroidal anti-inflammatory drug gastropathy . Arch Intern Med. 1987;;147:1798-1801.
21 +
Lanza FL, Aspinall RL, Swabb EA, et al.  Double-blind, placebo-controlled endoscopic comparison of the mucosal protective effects of misoprostol versus cimetidine on tolmentin-induced mucosal injury to the stomach and duodenum . Gastroenterology. 1988;;95:289-294.
22 +
Armstrong CP, Blower AL.  Non-steroidal anti-inflammatory drugs and life threatening complications of peptic ulceration . Gut. 1987;;28:527-532.
23 +
Caldwell JR, Roth SH, Wu WC, et al.  Sucralfate treatment of nonsteroidal anti-inflammatory drug-induced gastrointestinal symptoms and mucosal damage . Am J Med. 1987;;83( (suppl 3B) ):74-82.
24 +
Hillman AL, Bloom BS.  Economic effects of prophylactic use of misoprostol to prevent gastric ulcer in patients taking nonsteroidal anti-inflammatory drugs . Arch Intern Med. 1989;;149:2061-2065.
25 +
Weinstein MC, Stason WB.  Foundations of cost-effectiveness analysis for health and medical practices . N Engl J Med. 1977;;296:716-721.
26 +
Eisenberg JM.  Clinical economics: a guide to the economic analysis of clinical practices . JAMA . 1989;;262:2879-2897.
27 +
Hollenberg J. SMLTREE . Roslyn, NY: 1989;. Computer software.
28 +
Kurata JH.  Ulcer epidemiology: an overview and proposed research framework . Gastroenterology . 1989;;96:569-580.
29 +
National Health Survey. Detailed Diagnoses and Procedures for Patients Discharged From Short-stay Hospitals, United States, 1986 . Hyattsville, Md: National Center for Health Statistics; 1988;. Series 13, No. (95) .
30 +
Statistical Abstract of the United States 1988 . Washington, DC: Bureau of the Census; 1988;.
31 +
Kurata JH, Honda GD, Frankl H.  Hospitalization and mortality rates for peptic ulcers: a comparison of a large health maintenance organization and United States data . Gastroenterology . 1982;;83: 1008-1016.
32 +
Beard K, Walker AM, Perera DR, Jick H.  Nonsteroidal anti-inflammatory drugs and hospitalization for gastroesophageal bleeding in the elderly . Arch Intern Med. 1987;;147:1621-1623.
33 +
Bonnevie O.  The incidence of gastric ulcer in Copenhagen County . Scand J Gastroenterol. 1975;; 10:231-239.
34 +
Bonnevie O.  The incidence of duodenal ulcer in Copenhagen County . Scand J Gastroenterol. 1975;;10:385-393.
35 +
Coles LS, Fries JF, Kraines RG, Roth SH.  From experiment to experience: side effects of nonsteroidal anti-inflammatory drugs . Am J Med. 1983;;74:820-828.
36 +
Cucala M, Baurfeind P, Emde C, et al.  Is it wise to prescribe NSAIDs with modern gastroprotective agents? Scand J Rheumatol. 1987;;( (suppl 67) ):141-154.
37 +
Pounder R.  Silent peptic ulceration: deadly silence or golden silence? Gastroenterology . 1989;;96: 626-631.
38 +
Van Deventer GM, Elashoff JD, Reedy TJ, et al.  A randomized study of maintenance therapy with ranitidine to prevent the recurrence of duodenal ulcer . N Engl J Med. 1989;;320:1113-1119.
39 +
Lilienfeld AM, Lilienfeld DE. Foundations of Epidemiology . 2nd ed. New York, NY: Oxford University Press; 1980;.
40 +
Walt R, Katschininski B, Logan R, et al.  Rising frequency of ulcer perforation in elderly people in the United Kingdom . Lancet . 1986;;1:489-492.
41 +
Vital Statistics of the United States 1986: Mortality, Part A . Hyattsville, Md: National Center for Health Statistics; 1988;;2.
42 +
Committee on Safety of Medicines.  Non-steroidal anti-inflammatory drugs and serious gastrointestinal side-effects . BMJ . 1986;;292:614.
43 +
Mitchell DM, Spitz PW, Young DY, et al.  Survival, prognosis, and causes of death in rheumatoid arthritis . Arthritis Rheum. 1986;;29:706-714.
44 +
Symmons DPM.  Mortality in rheumatoid arthritis . Br J Rheumatol. 1988;;27( (suppl 1) ):44-54.
45 +
Willems JS, Sanders CR, Riddiough MA, et al.  Cost-effectiveness of vaccination against pneumococcal pneumonia . N Engl J Med. 1980;;303:553-559.
46 +
Edelson JT, Weinstein MC, Tosteson ANA, et al.  Long-term cost-effectiveness of various initial mono-therapies for mild to moderate hypertension . JAMA . 1990;;263:408-413.
47 +
Goldman L, Sia STB, Cook EF, et al.  Costs and effectiveness of routine therapy with long-term beta-adrenergic antagonists after acute myocardial infarction . N Engl J Med. 1988;;319:152-157.
48 +
Kinosian BP, Eisenberg JM.  Cutting into cholesterol . JAMA . 1988;;259:2249-2254.
49 +
Butt JH, Barthel JS, Moore RA.  Clinical spectrum of the upper gastrointestinal effects of nonsteroidal anti-inflammatory drugs . Am J Med. 1988;;84( (suppl 2A) ):5-14.
50 +
Beck JR, Pauker SG.  The Markov process in medical prognosis . Med Decis Making. 1983;;3:421-458.
51 +
Stason WB, Weinstein MC.  Allocation of resources to manage hypertension . N Engl J Med. 1977;;296:732-739.

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