Cost-Benefit Assessment of Salicylates and NSAIDs in Treating Arthritic Disease

Abstract

The increasing costs of treating rheumatic diseases has presented a serious challenge to contain the projected expenditures of $96.8 billion by the year 2000. This includes both direct and indirect costs to the patient and society. These expenditures include physician care, prescribed drugs, patient aids, physical and occupational therapy, nursing care, hospitalization, and nursing home care. Indirect costs include lost wages, insurance indemnification, loss of productivity, disability and pension payments, and rehabilitation expenses rendered by government agencies. Sparcity of data presents problems in addressing this onerous tax on society. In 1985 Baum reported that 66.5 million prescriptions for nonsalicylate nonsteroidal anti-inflammatory drugs (NSAIDs) were prescribed in the United States at a cost of over $1 billion. Salicylates were not included. Cost-effectiveness of salicylates v nonsalicylate NSAIDs is reviewed. Most studies carried out have not appropriately presented these comparative data. The thesis of this article addresses the false premise that basic drug cost is the only consideration in prescribing. If the studied therapeutic group has displayed significant adverse reactions, the cost of managing such toxicity must be considered. The studies presented refer to the most commonly encountered side effect with NSAIDs and salicylates, namely, gastropathy. True costs of a NSAIDs, therefore, involves factoring in the treatment of this gastric harm. Our previously published retrospective study revealed that the incidence of bleeding ulcers produced by salicylates was 3.6% v 1.3% for nonsalicylate NSAIDs. The costs of hospitalization disclosed that salicylates do not represent the most economical agent. Further studies were discussed, presenting the many confounding biases of both retrospective and controlled prospective studies. This article suggests that there is insufficient proof of efficacy to substitute enteric-coated and nonacetylated salicylates. Indeed, gastric ulcers and flareup of old duodenal ulcers have occurred with these so-called safer agents. True cost-effectiveness may require review of thousands of patient records in nonrandomized retrospective studies in order to determine an accurate assessment. Furthermore, experiments to disclose the cost-effectiveness of adding modalities directed at protecting the gastric mucosa in NSAID users are required in order to determine cost benefits.