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Sameer D. Saini, MD, MSc; Philip Schoenfeld, MD, MSEd, MSc (Epi); A. Mark Fendrick, MD; James Scheiman, MD

Arch Intern Med. 2008;168(15):1684-1690.

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.

Author Affiliations: Departments of Internal Medicine and Gastroenterology, University of Michigan Medical School (Drs Saini, Schoenfeld, Fendrick, and Scheiman) and Veteran Affairs Center for Excellence in Health Services Research (Dr Schoenfeld), Ann Arbor. Dr Saini is now also with the Veterans Affairs Center for Excellence in Health Services Research.

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