Cost-utility of aspirin and proton pump inhibitors for primary prevention

Arch Intern Med. 2011 Feb 14;171(3):218-25. doi: 10.1001/archinternmed.2010.525.


Background: Aspirin reduces myocardial infarction but increases gastrointestinal tract (GI) bleeding. Proton pump inhibitors (PPIs) may reduce upper GI bleeding. We estimate the cost-utility of aspirin treatment with or without a PPI for coronary heart disease (CHD) prevention among men at different risks for CHD and GI bleeding.

Methods: We 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. We 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 2-fold. Adding a PPI reduced upper GI bleeding by 80%. Annual aspirin cost was $13.99; the generic PPI cost was $200.00.

Results: In 45-year-old men with a 10-year CHD risk of 10% and 0.8 per 1000 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- 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 to 6 per 1000.

Conclusions: Treatment with aspirin for CHD prevention is less costly and more effective than no treatment in men older than 45 years with greater than 10-year, 10% CHD risks. Adding a PPI 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.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aspirin / adverse effects
  • Aspirin / economics*
  • Aspirin / therapeutic use
  • Coronary Disease / economics*
  • Coronary Disease / prevention & control*
  • Cost-Benefit Analysis / statistics & numerical data
  • Drug Costs / statistics & numerical data*
  • Drug Therapy, Combination
  • Gastrointestinal Hemorrhage / chemically induced
  • Gastrointestinal Hemorrhage / economics*
  • Gastrointestinal Hemorrhage / prevention & control*
  • Health Care Costs / statistics & numerical data
  • Humans
  • Male
  • Markov Chains
  • Middle Aged
  • Myocardial Infarction / economics*
  • Myocardial Infarction / prevention & control*
  • Platelet Aggregation Inhibitors / adverse effects
  • Platelet Aggregation Inhibitors / economics*
  • Platelet Aggregation Inhibitors / therapeutic use
  • Proton Pump Inhibitors / adverse effects
  • Proton Pump Inhibitors / economics*
  • Proton Pump Inhibitors / therapeutic use
  • Quality-Adjusted Life Years
  • Risk Assessment / economics
  • Risk Assessment / statistics & numerical data
  • United States


  • Platelet Aggregation Inhibitors
  • Proton Pump Inhibitors
  • Aspirin