Cost-Utility of Aspirin and Proton Pump Inhibitors for Primary Prevention

Study Questions:

What is the cost-utility of aspirin treatment with or without a proton pump inhibitor (PPI) for coronary heart disease (CHD) prevention among men at different risks for CHD and gastrointestinal (GI) bleeding?


The authors updated a Markov model to compare costs and outcomes of low-dose aspirin plus PPI (omeprazole, 20 mg/d), low-dose aspirin alone, or no treatment for CHD prevention. They performed lifetime analyses in men with different risks for cardiovascular events and GI bleeding. Aspirin reduced nonfatal myocardial infarction by 30%, increased total stroke by 6%, and increased GI bleeding risk twofold. Adding a PPI reduced upper GI bleeding by 80%. Annual aspirin cost was $13.99; the generic PPI cost was $200.00.


In 45-year-old men with a 10-year CHD risk of 10% and 0.8 per 1,000 annual GI bleeding risk, aspirin ($17,571 and 18.67 quality-adjusted life-years [QALYs]) was more effective and less costly than no treatment ($18,483 and 18.44 QALYs). Compared with aspirin alone, aspirin plus PPI ($21,037 and 18.68 QALYs) had an incremental cost per QALY of $447,077. Results were similar in 55-year-old and 65-year-old men. The incremental cost per QALY of adding a PPI was less than $50,000 per QALY at annual GI bleeding probabilities greater than 4-6 per 1,000.


The authors concluded that adding a PPI to aspirin therapy is not cost-effective for men with average GI bleeding risk, but may be cost-effective for selected men at increased risk for GI bleeding.


This analysis supports the role of aspirin for primary prevention of CHD events in middle-aged men across a range of CHD and GI bleeding risk levels. Increased risk of GI bleeding does not appear to reduce aspirin’s net benefit until GI bleeding risk becomes quite high, such as the level seen in men with previous GI bleeding. Adding PPI therapy does not appear to be cost-effective for those patients at low or average risk for GI bleeding, but may be valuable for those with a GI bleeding risk over 4 per 1,000 per year. Further efforts to include GI bleeding risk assessment when prescribing low-dose aspirin for CHD protection are indicated to optimize and individualize therapy.

Clinical Topics: Dyslipidemia, Prevention, Lipid Metabolism

Keywords: Myocardial Infarction, Proton Pumps, Coronary Disease, Risk Assessment, Gastrointestinal Hemorrhage, Proton Pump Inhibitors, Primary Prevention

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