AIM: Treating CHD with aspirin is cheaper, more effective than no treatment
Treating coronary heart disease (CHD) with aspirin was cheaper and more effective than no treatment in men aged 45 years or older who had more than a 10-year, 10 percent CHD risk, according to a study in the Feb. 14  Archives of Internal Medicine. Adding proton pump inhibitors for men at an increased risk, but not average risk, for GI bleeding is cost effective.

Stephanie R. Earnshaw, PhD, of the RTI Health Solutions, a research institute located in Research Triangle Park, N.C., and colleagues compared the cost and outcomes of low-dose aspirin plus PPI (omeprazole, 20 mg/d), low-dose aspirin alone or no treatment for CHD prevention in men aged 45 who had a 10-year CHD risk that equaled 10 percent. The researchers also performed analyses in men who had different risks of CV events and GI bleeding.

The researchers reported that aspirin reduced nonfatal MI by 30 percent but, increased total stroke by 6 percent and GI bleeding two-fold. Adding a PPI to aspirin treatment reduced upper GI bleeding events by 80 percent.

“Decisions about which men should receive low-dose aspirin for CHD prevention involve trade-offs between aspirin’s adverse effects and its beneficial effects,” Earnshaw and colleagues wrote.

As far as cost of the treatments, the annual cost of aspirin was reported to be $13.99, while the generic PPI administered during the study was $200.

For 45-year old men with CHD risk, those taking aspirin versus those who underwent no treatment had a higher rate of quality-adjusted life years (QALYs), 18.67 versus 18.44. Treating these patients with aspirin was less costly over a man’s remaining lifetime compared with no treatment, $17,571 versus $18,484.

In addition, the men taking a PPI on top of aspirin gained more QALYs (18.68) but saw higher cost ($21,037) when compared with men administered aspirin alone. The incremental cost per QALY with aspirin plus PPI when compared to aspirin alone was $447,077, “suggesting that the addition of PPI prophylaxis was not cost effective,” the authors wrote.

While the authors noted that adding a PPI onto aspirin treatment can be expensive, the incremental cost per QALY of aspirin plus PPI compared to aspirin alone was less than $50,000. The annual GI bleeding risk was four in 1,000 patients and had a cost-savings when GI bleeding risk was greater than seven in 1,000.

“Overall, as GI bleeding risk increased, the incremental cost per QALY of aspirin plus PPI compared with aspirin alone was lower in younger men because they received cardiovascular benefits of aspirin over longer periods of time (their lifetime),” the authors wrote.

The authors added that adding a PPI when GI bleeding risk was five per 1,000 per year for men aged 45 years showed a cost-effectiveness ratio of $22,000 per QALY gained a four-fold increase in baseline bleeding risk.

“Assuming a branded cost of a PPI at $1,951 per year, a man’s GI bleeding risk would need to be 6.7 per 100 per year (over 10 times higher than our base case) for the addition of a PPI to be cost effective in a man with the same CHD risk,” the authors wrote.

The authors noted that an increased risk of GI bleeding does not reduce aspirin’s benefit until it is very high. In addition, while adding PPI treatment is not cost effective for men at a low or average risk for bleeding, it could be beneficial for those who have a GI bleeding risk of over four per 1,000 per year, the authors concluded.