Objectives: Erosive esophagitis is a recurring condition for which many patients require preventive therapy. If maintenance therapy must be provided, the most cost-effective treatment strategy should be established. We evaluated the costs and benefits associated with three treatment strategies: 1) maintenance therapy with a proton pump inhibitor (PPI) strategy, 2) maintenance therapy with a high-dose histamine-2 receptor antagonist (H2RA) strategy, and 3) maintenance therapy with a standard-dose H2RA. If patients experience a symptomatic recurrence on the H2RA strategies, they then receive PPI maintenance.
Methods: We used a cost-effectiveness model with a 1-yr time frame; data were obtained from randomized trials of lansoprazole and ranitidine, from case series, and expert opinion.
Results: In most situations, the high-dose H2RA strategy is the most costly, yet it is less effective than the PPI strategy. Among the remaining two options, the PPI strategy is more costly and more effective than the standard-dose H2RA strategy, requiring an additional $52-688 per recurrence prevented, depending on drug acquisition costs. The greater the degree to which esophagitis decreases quality of life, the more cost effective is the PPI strategy. For example, with a $50,000 per quality-adjusted life year cost-effectiveness threshold and a market-weighted average of drug costs, the PPI strategy appears cost effective for those patients who report that symptoms of esophagitis cause greater than a 9% decrement in quality of life.
Conclusions: The high-dose H2RA strategy is not preferred in terms of either costs or benefits. The PPI strategy appears cost effective relative to the standard-dose H2RA strategy in the following situations: when patients are significantly bothered by esophagitis and in institutional settings where the difference in drug costs between PPIs and H2RAs is small.