Economic and health aspects of peptic ulcer disease and H2-receptor antagonists

  • Dennis M. Jensen
    Requests for reprints should be addressed to Dr. Dennis M. Jensen, 44-133 CHS, Division of Gastroenterology, UCLA Center for the Health Sciences, Los Angeles, California 90024.
    Divisions of Gastroenterology, UCLA School of Medicine, Wadsworth Veterans Administration Hospital, and the Center for Ulcer Research and Education (CURE), Los Angeles, California, USA
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      The costs of peptic ulcer disease to society are very high. Costs can be expressed as either direct or indirect. Direct costs include hospitalization or clinic visits, physicians' fees, and medication. Indirect costs are loss of productivity due to absenteeism from work or loss of income from death of an employee. The daily cost of different ulcer drugs such as the histamine (H2)-receptor antagonists for intravenous treatment, acute healing, and maintenance can easily be compared. As newer anti-ulcer drugs such as H2-receptor antagonists have been introduced into the marketplace, the number of prescriptions and medication costs have increased rather than decreased. In part, this may be accounted for by the high frequency with which H2 antagonists are prescribed for patients with non-ulcer dyspepsia. Some patients have chronic peptic ulcer disease with multiple painful recurrences or complications such as hemorrhage, perforation, or obstruction. They may require long-term care or drug maintenance, hospitalization, or surgery. For patients with chronic ulcer disease or complications, randomized controlled trials to compare the efficacy, safety, and costs of different forms of therapy (maintenance drugs, surgery, or placebo) have not been reported. However, based upon good efficacy and safety for acute healing and long-term drug maintenance for painful duodenal ulcer disease, long-term maintenance with H2-receptor antagonists is now prescribed for many patients. No controlled randomized trials have been reported to document that long-term maintenance with H2-receptor antagonists actually reduces peptic ulcer complications. However, by current cost estimates, long-term H2-receptor antagonist therapy is less expensive than ulcer surgery for uncomplicated ulcer disease for up to eight years. However, maintenance drug therapy after eight years may be more expensive than elective ulcer surgery in patients with chronic peptic ulcer disease who are good surgical candidates. Patients with complications of peptic ulcer disease seem to represent a different subset than patients with symptomatic ulcer disease. Further studies in these subsets are needed to ascertain the most effective, safest, and least expensive management such as surgery, long-term drug maintenance, or intermittent drug therapy to prevent recurrent ulceration or complications. Because of excellent efficacy and safety in controlled clinical trials of symptomatic peptic ulcer disease and the pattern of utilization in other countries such as Japan, famotidine is likely to capture a significant proportion of the H2-receptor antagonist market in the United States. Based upon recent patterns of utilization for H2-receptor antagonists and the cost of developing novel drugs, it seems unlikely that the introduction of new ulcer drugs such as famotidine will further reduce the direct or indirect costs of peptic ulcer disease in the United States. Nevertheless, studies assessing the impact of such anti-ulcer drugs upon the direct and indirect costs of peptic ulcer disease are recommended.
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