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Abstract Number: 2235

Cost-Effectiveness of Long-Term Opioid Use in the Treatment of Knee Osteoarthritis in Older Patients with Multiple Comorbidities  

Jeffrey N. Katz1, Savannah Smith2, Jamie E. Collins3, Joanne M. Jordan4, David J. Hunter5, Edward H. Yelin6, Lisa Suter7, A. David Paltiel8 and Elena Losina3, 1Rheumatology and Orthopedics, Brigham and Women's Hospital, Boston, MA, 2Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA, 3Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA, 4University of North Carolina Dept of Epidemiology, Chapel Hill, NC, 5Rheumatology, Institute of Bone and Joint Research, Kolling Institute, University of Sydney, Sydney, Australia, 6Arthritis Research Group, University of California, San Francisco, San Francisco, CA, 7Medicine, Rheumatol, TAC S541, Yale University, New Haven, CT, 8Yale School of Public Health, New Haven, CT

Meeting: 2014 ACR/ARHP Annual Meeting

Keywords: Economics, Nonsteroidal antiinflammatory drugs (NSAIDs), opioids, osteoarthritis and tramadol

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Session Information

Session Title: Osteoarthritis - Clinical Aspects: Therapeutics

Session Type: Abstract Submissions (ACR)

Background/Purpose: Because older patients with osteoarthritis (OA) and multiple comorbidities face high risk of toxicity from nonselective non-steroidal antiinflammatory drugs (NSAIDs) and Cox-2 inhibitors, opiates (including tramadol) have been proposed as an analgesic strategy. We evaluated clinical and economic outcomes of using prototypic medications (tramadol, naproxen, and celecoxib) in such patients.

Methods: We used the Osteoarthritis Policy Model, a validated computer simulation of knee OA, to project long-term clinical outcomes, costs and incremental cost-effectiveness ratios (ICERs) of OA treatment strategies in patients with mean age 70, knee OA, diabetes and coronary heart disease whose pain persists after initial therapy with acetaminophen, steroid injections and physical therapy (PT). We examined four treatment strategies: 1) continuing PRN acetaminophen; 2) tramadol; 3) naproxen and 4) celecoxib. Pain was the primary determinant of quality of life and its relief was assessed with the Western Ontario McMaster (WOMAC) Pain Scale. Treatment efficacies and toxicities were estimated from published literature and influenced time on regimen. Mean WOMAC change was 22 points for tramadol; 15 for naproxen and celecoxib. Annual medication costs and major toxicities for the first and subsequent years are shown in the Table. Toxicities included CVD and – for tramadol — fractures. We adopted a societal perspective, discounting outcomes at 3%, and assumed a willingness to pay (WTP) of $100,000 per quality adjusted life year (QALY) gained. ICERs below this threshold defined cost-effective strategies.  

Results: Patients remained on tramadol for 1.98 years and the other regimens for 2.36 years. Twice as many experienced major toxicity with tramadol as with the other agents.  The Table lists the cost-effectiveness results. The ICER for tramadol exceeded that for naproxen; thus, we compared naproxen directly to PRN acetaminophen and observed that naproxen had an ICER of $78,848/QALY. However, tramadol cost effectiveness was highly sensitive to its toxicity. When tramadol toxicity was reduced by just 10% it became cost-effective (ICER $53,968/QALY), and ICERs for the naproxen-based strategy then exceeded the WTP threshold (ICER=$102,000/QALY) compared to the tramadol-based strategy.

Conclusion: In patients with OA and multiple comorbidities who have pain despite acetaminophen, steroid injection and PT, naproxen was cost-effective at a WTP=$100,000. Tramadol became cost effective following a 10% reduction in its overall toxicity. The cost of celecoxib precluded its offering acceptable value. The impact of tramadol toxicity on these estimates underscores the need for further research on toxicity of opiates in frail patients; the limited number of years on regimen highlights the need for therapies with better efficacy and toxicity profiles.

 

Table: Cost-effectiveness, toxicity and years on regimen among individuals treated with acetaminophen, tramadol, naproxen and celecoxib

Inputs

 

Results

Toxicity

Costs

QALE

COST

ICERs

Average Years on Regimen

Proportion Experiencing Major Toxicity attributable to treatment

Regimen

(first yr,

subseq yrs)

Acetaminophen PRN

$71

6.328

$131,558

 

 

 

Tramadol

21%, 6.0%

$755

6.363

$133,817

Dominated

1.98

33.7%

Naproxen

9.3%, 4.8%

$2,642

6.410

$137,983

$78,848

2.36

15.3%

Celecoxib

 9.5%, 4.9%

$4,750

6.406

$142,610

Dominated

2.36

15.5%

PRN = as needed; Toxicity=coronary heart disease, gastrointestinal, fracture

QALE=quality adjusted life expectancy; ICER = incremental cost effectiveness ratio. 

Dominated = Agent costs more and provides less benefit than some other agent or combination of agents

 

 


Disclosure:

J. N. Katz,
None;

S. Smith,
None;

J. E. Collins,
None;

J. M. Jordan,

Algynomics,

5,

Samumed,

5,

Flexion,

5,

ClearView Healthcare Partners,

5,

Trinity Partners, LLC,

5;

D. J. Hunter,
None;

E. H. Yelin,
None;

L. Suter,
None;

A. D. Paltiel,
None;

E. Losina,
None.

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