Cost-effectiveness of proton pump inhibitor cotherapy in patients taking long-term, low-dose aspirin for secondary cardiovascular prevention

Arch Intern Med. 2008 Aug 11;168(15):1684-90; discussion 1691. doi: 10.1001/archinte.168.15.1684.


Background: Patients with coronary heart disease (CHD) require long-term therapy with low-dose aspirin (ASA). Although these patients are at increased risk for upper gastrointestinal bleeding (UGIB) and proton pump inhibitor (PPI) cotherapy may reduce such risk, it is not known whether lifelong PPI cotherapy is cost-effective.

Methods: A Markov model was developed to compare lifelong therapy with ASA alone vs therapy with ASA plus PPI in patients with CHD who are at least 50 years old. Base-case assumptions were (1) starting age, 65 years (range, 50-80 years); (2) UGIB risk category, average risk (range, average to 8-fold increased risk); (3) PPI effectiveness (66% (range, 25%-75%); and (4) annual PPI cost, $250 (range, $250-$1400).

Results: In the base-case analysis, ASA plus PPI resulted in fewer lifetime UGIB events (3.1% vs 9.5%) and UGIB-related deaths (0.4% vs 1.4%). At over-the-counter (OTC) PPI cost, ASA plus PPI was cost-effective, with an incremental cost-effectiveness ratio (ICER) of $40,090 per life-year saved (LYS). Varying PPI effectiveness from 75% to 25% resulted in ICERs of $35,315 to $94,578 per LYS. Varying the starting age of the cohort from 80 to 50 years resulted in ICERs of $16,887 to $79,955 per LYS. At prescription PPI cost, the ICER for average-risk patients was over $100,000 per LYS across all modeled age groups and assumptions of PPI effectiveness, but the ICER for high-risk patients was $10,433 to $51,505 per LYS.

Conclusions: At OTC cost, PPI cotherapy is cost-effective in average-risk patients taking low-dose ASA for secondary prevention. At prescription cost, cotherapy is cost-effective for high-risk patients only.

MeSH terms

  • Aged
  • Aspirin / economics*
  • Aspirin / therapeutic use
  • Cardiovascular Diseases / prevention & control*
  • Coronary Disease / drug therapy
  • Cost-Benefit Analysis
  • Dose-Response Relationship, Drug
  • Drug Therapy, Combination
  • Gastrointestinal Hemorrhage / chemically induced
  • Humans
  • Markov Chains
  • Middle Aged
  • Models, Economic
  • Platelet Aggregation Inhibitors / economics*
  • Platelet Aggregation Inhibitors / therapeutic use
  • Proton Pump Inhibitors / economics*
  • Proton Pump Inhibitors / therapeutic use
  • Risk Assessment


  • Platelet Aggregation Inhibitors
  • Proton Pump Inhibitors
  • Aspirin