Table 6.

Cost-effectiveness of Step-down PPI Treatment.

Author	Year	Methodology	Outcome	Conclusion	Limitation
Cahir et al14 (Ireland)	2012	• The National Shared Services Primary Care Reimbursement Service of the Health Service Executive in Ireland (HSE-PCRS) pharmacy provides free health services, including medications to eligible persons in Ireland. • Drugs are categorized into 4 classes: unbranded generic, branded generic, proprietary drug with a generic equivalent, and proprietary drug with no generic equivalent. • Five scenarios were identified according to published National Institute for Health and Care Excellence clinical guidelines for more cost-effective PPI prescribing: - Least expensive PPI at initiation - Therapeutic switching (cheaper brand/generic equivalent) - Dose reduction - Therapeutic switching and dose reduction - Therapeutic substitution • Costs were calculated as the NIC of the dispensed PPI and the total expenditure which included NIC and pharmacist dispensing fee.	• The greatest cost savings were obtained by switching patients’ PPI therapy to the least expensive PPI and also stepping patients down to maintenance dose after 3 consecutive months at maximum therapeutic dosage. • Regular maintenance low dose of most PPIs will prevent recurrent GERD symptoms in 70% to 80% of patients. • In the United States, 48% of Veterans adopted step-down therapy, whereas 58% of patients on long-term PPI therapy discontinued PPI use and remained asymptomatic with no significant change in quality of life after 1 year. • Total NIC was US$94 128 196.13 for claimants on PPI therapy during 2007. The estimated costing savings for each of the 5 scenarios in a 1-year period were: - US$39 447 368.13 (42% reduction); - US$31 572 626.24 (34%); - US$22 732 312.25 (24%); - US$43 250 442.78 (46%); - (v) US$37 363 297.55 (40%).	• PPIs are highly effective but they are being overprescribed in Ireland for longer durations and at higher doses than current guidelines advice. • As PPIs lose patent protection and cheaper generic equivalents become available on the market, potential cost savings could be obtained with limited impact on clinical outcomes.	• Lack of detailed diagnostic information that determines clinical indications for PPI therapy in the database limited the investigation of individual patient factors and differences in drug indication

Note. PPI = proton pump inhibitor; NIC = net ingredient cost; GERD = gastroesophageal reflux disease.