Purpose: Non-selective non-steroidal anti-inflammatory drugs (nsNSAIDs) have been associated with serious AEs including gastrointestinal (GI) toxicity. In contrast, celecoxib has demonstrated a superior GI safety profile.  Numerous publications have demonstrated that patients at increased risk for GI complications are being channeled to celecoxib as first line treatment while patients with lower risk are channeled to celecoxib only after nsNSAID failure and first GI event. Our objective is to assess the cost-utility of 3 different treatment strategies for arthritis including celecoxib as 1^st line, 2^nd line, and 3^rd line treatment. 

Methods: A decision analytic framework was used to model the movement of low GI risk and high GI risk cohort of arthritis patients over 5 year time horizon based on one-month cycles. High GI risk patients are defined as individuals ≥ 65 years.  1^st line of treatment was defined as patients starting on celecoxib. 2^nd  line: patients start on naproxen and switch to celecoxib after 1^st GI event. 3^rd line: patients start on naproxen, add a PPI after 1^st GI event, and switch to celecoxib after 2^nd GI event. Model inputs were determined through a comprehensive literature search of MEDLINE and EMBASE from 1995 - 2006.  Included studies evaluated GI events: dyspepsia, uncomplicated and complicated ulcers, death.  Drug and procedure costs were derived from Canadian published sources.

Results: Total cost ($CAD 2005) for celeberex 1^st, 2^nd, and 3^rd line were respectively $4562, $3189, and $3256. Total QALYs for celeberex 1^st, 2^nd, and 3^rd line were respectively 3.294, 3.273, and 3.273.  The cost per QALY ratio in 2^nd vs. 3^rd line was dominant, and in 2^nd vs 1^st line was $67,304. In a sub-group analysis of patients with high GI risk only, celecoxib showed to be cost-effective ($51,000/QALY) as 1^st line treatment compared to celecoxib 2^nd line.

Conclusion:  Even though 2^nd line and 3^rd line use of celecoxib result in similar effectiveness (QALY), the total cost associated with celecoxib 2^nd line is lower than the cost associated with celecoxib 3^rd line. This analysis supports the current listing status of celecoxib as a full benefit on the Quebec drug program and the general use of celecoxib before a PPI agent in the treatment for pain and inflammation.