Medical management of gallstones

Abstract

Ursodeoxycholic acid (ursodiol) is an oral dissolution agent recently approved by the Food and Drug Administration for treatment of cholelithiasis. The authors conducted a cost-effectiveness analysis comparing ursodiol with elective cholecystectomy and expectant management for men and women of ages 50 and 70 with typical chronic biliary symptoms. Using published literature and national cost data, the authors performed a decision analysis in which the outcome measures were life expectancy, quality-adjusted life expectancy, and expected lifetime treatment cost. The analysis applies to patients with symptoms of biliary colic, noncalcified gallstones less than 20 mm in diameter, and functioning oral cholecystograms, who are candidates for elective cholecystectomy. Excluded were patients with acute cholecystitis or known or suspected common bile duct stones. Ursodiol is both clinically advantageous and less expensive than surgery for symptomatic men aged 64 or more, and for symptomatic women aged 69 or more. At ages younger than these, the clinical advantage of surgery is small and could be nullified if ursodiol were targeted at patients for whom dissolution is most likely to be effective, based on evidence of stone size and composition. Expected lifetime costs of ursodiol range from $300-400 more than surgery for 50-year-olds to $700-1,000 less than surgery for 70-year-olds. Ursodiol is the preferred choice for patients throughout this age range who are at significantly elevated risk of operative mortality. Ursodiol is a clinically advantageous and cost-effective alternative to elective cholecystectomy, especially for older and high-risk patients.