Proton Pump Inhibitors Are More Cost-Effective Than Potassium Competitive Acid Blockers for Gastroesophageal Reflux Disease

INTRODUCTION: Potassium competitive acid blockers (PCABs) are superior to proton pump inhibitors (PPIs) for healing of Los Angeles (LA) class C/D erosive esophagitis and are approved for nonerosive gastroesophageal reflux disease (GERD) given their efficacy measured by heartburn-free days. However, they are more expensive than PPIs. We estimated the cost-effectiveness of PCABs compared with PPIs for the management of GERD. METHODS: A decision tree was constructed for the base case of a patient with GERD. We tested scenarios in which nonerosive reflux disease, LA A/B, or LA C/D esophagitis was present, comparing PCABs with PPIs as first-line therapy, including step up therapy and/or class switching if symptoms persisted. Using publicly available cost estimates, quality-adjusted life years (QALYs) were compared using a willingness-to-pay threshold of $100,000/QALY from a societal perspective at 6 months. RESULTS: The cost of PCABs for GERD was $3,240 more than PPIs, with an incremental cost-effectiveness ratio of $144,208/QALY. When evaluating GERD phenotypes separately, the incremental cost-effectiveness ratio was consistently over our willingness-to-pay threshold. One-way analyses showed the most influential parameters were PCAB cost and efficacy for heartburn-free days. Probabilistic sensitivity analysis favored PPIs 71.7% out of 100,000 iterations. Reducing one-week costs to below $91 would make PCABs a cost effective first-line strategy across all GERD phenotypes. DISCUSSION: Despite PCAB efficacy, PPIs are a cost-effective strategy for GERD treatment, and can be positioned ahead of PCAB escalation on this basis. Reducing PCAB costs or accepting a higher willingness-to-pay threshold would influence this finding, although PCABs may be favored in some current situations as evidenced by probabilistic sensitivity results.