Purpose: Approximately 1% of patients taking non-steroidal anti-inflammatory (NSAID) medication will suffer a bleeding peptic ulcer per year. As many patients with arthritis are dependent on NSAIDs to maintain mobility, a number of strategies have been studied to prevent recurrent bleeding. These include eradication of Helicobacter pylori and co-prescription of misoprostol or a proton pump inhibitor (PPI). Data are now available from Cochrane systematic reviews as to the effectiveness of these approaches. This model aimed to determine the cost-effectiveness of the strategies

Methods: The software DataPro 2005 (Treeage) was used. A Markov model was used to predict monthly recurrence over 5 years, and values obtained for baseline risk, effect of therapy, costs and utilities using Cochrane meta-analyses and published national cost data. Varaibles were specified as Beta binomial (for proportions), Lognormal (for Relative risk) or Gamma distributions (for costs). Six strategies were compared, do nothing, misoprostol, PPI, H.pylori eradication alone, H.pylori eradication with misoprostol after and H.pylori eradication with PPI after. A 1000 trial Monte Carlo Simulation was carried out.

Results: H.pylori eradication alone dominated all the other strategies except H.pylori eradication followed by misoprostol. H.pylori eradcation alone produced a mean of 4.14 QALYs over 5 years at a cost of $78.84 per patient. Adding maintenance misoprostol after eradication added an additional 0.002 QALYs at an ICER of $651,000 per QALY. Probabilistic sensitivity analysis showed that H.pylori eradication alone dominated the other strategies with a likelihood of 90% of being the most cost-effective strategy at $1,350,000 per QALY. At $50,000 per QALY there was only a 1% chance that adding misoprostol would be cost-effective.

Conclusion: H.pylori eradication therapy is the preferred strategy for the prevention of recurrent NSAID-related peptic ulcer bleeds, it is more effective and less costly than other strategies, except adding misoprostol co-prescription. However adding misoprostol is not cost-effective at any reasonable willingness to pay.