Although proton pump inhibitors (PPIs) are the most expensive acid-reducing agents, it is important to assess all direct and indirect costs, such as loss of work productivity and impact on quality of life associated with the treatment of gastroesophageal reflux disease (GERD). Multiple pharmacoeconomic analyses have attempted to identify the best treatment strategy among step-down, step-up, intermittent, and on-demand treatment approaches. Gerson and colleagues have developed the most comprehensive model comparing the broadest number of strategies.They constructed an analytic model based on a hypothetical cohort of 40-year-old adults presenting with typical gastroesophageal reflux disease (GERD) symptoms. Six treatment arms were compared. Strategy 1, lifestyle therapy including antacids, was used as a reference case and compared with the following: 2) H2RA therapy (endoscopy if no response); 3) step-up starting with H2RA followed with PPI for nonresponders (endoscopy if no response with eight weeks of PPI); 4) step-down therapy starting with eight weeks of PPI followed by eight weeks of H2RA and antacids if symptomatic response to PPI (endoscopy if no response to PPI) and antacid therapy if response to H2RA therapy; 5) PPI-on-demand therapy; daily PPI for eight weeks, followed by eight-week courses on an as-needed basis for symptom recurrence, with no more than three courses a year (endoscopy for nonresponders); and 6) PPI-continuous therapy (endoscopy for nonresponders).
Outcomes measured were lifetime costs, quality-adjusted life years (QALYs) gained, and incremental cost-effectiveness. Results showed initial therapy with proton pump inhibitors (PPIs) followed by on-demand therapy was the most cost-effective approach, with a cost-effectiveness ratio of $37,923 for patients with mild gastroesophageal reflux disease (GERD) symptoms and $20,934 per QALY gained for patients with moderate to severe GERD symptoms. The PPI-on-demand strategy was more effective and less costly than the step-up approach or the other treatment arms. The results did not change with varying cost of therapy, QALY adjustment from gastroesophageal reflux disease (GERD) symptoms, or the success rate of the lifestyle arm. The step-up approach was only cost-effective when PPI-on-demand strategy success rate was less than 60%.
Role of the Pharmacist
Gastroesophageal reflux disease (GERD) is a multifaceted disease with serious complications if left untreated. Pharmacists can play a key role in the management of GERD by monitoring patients’ therapy, by providing patient education, and through appropriate referral. Patient self-management is appropriate only with mild symptoms that resolve with OTC (over-the-counter) therapy. If symptoms continue or if become more severe, the patient should be referred to a physician. When a patient seeks advice for the treatment of heartburn, the pharmacist should thoroughly assess symptoms, contributing factors, and medication history. Patients presenting with any warning signs should be referred to a doctor immediately. With recent availability of Prilosec OTC, pharmacists need to provide patient education and attempt to ensure its appropriate use. Patients diagnosed with GERD or presenting with heartburn that does not improve after two weeks of treatment should be instructed to seek medical help. Pharmacists also play an important role by advising prescribers of relative efficacies and toxicities, and cost-effectiveness of treatments for long-term management of gastroesophageal reflux disease (GERD). Pharmacists can also assist patients in understanding treatment regimens and remind them of lifestyle changes that may help to alleviate symptoms.