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Ann Intern Med. 2014 Feb 18;160(4):221-32.

Cost-effectiveness of genotype-guided and dual antiplatelet therapies in acute coronary syndrome.

Abstract

BACKGROUND:

The choice of antiplatelet therapy after acute coronary syndrome (ACS) is complicated: Ticagrelor and prasugrel are novel alternatives to clopidogrel, patients with some genotypes may not respond to clopidogrel, and low-cost generic formulations of clopidogrel are available.

OBJECTIVE:

To determine the most cost-effective strategy for dual antiplatelet therapy after percutaneous coronary intervention for ACS.

DESIGN:

Decision-analytic model.

DATA SOURCES:

Published literature, Medicare claims, and life tables.

TARGET POPULATION:

Patients having percutaneous coronary intervention for ACS.

TIME HORIZON:

Lifetime.

PERSPECTIVE:

Societal.

INTERVENTION:

Five strategies were examined: generic clopidogrel, prasugrel, ticagrelor, and genotyping for polymorphisms of CYP2C19 with carriers of loss-of-function alleles receiving either ticagrelor (genotyping with ticagrelor) or prasugrel (genotyping with prasugrel) and noncarriers receiving clopidogrel.

OUTCOME MEASURES:

Direct medical costs, quality-adjusted life years(QALYs), and incremental cost-effectiveness ratios (ICERs).

RESULTS OF BASE-CASE ANALYSIS:

The clopidogrel strategy produced$179 301 in costs and 9.428 QALYs. Genotyping with prasugrel was superior to prasugrel alone, with an ICER of $35 800 per QALY relative to clopidogrel. Genotyping with ticagrelor was more effective than genotyping with prasugrel ($30 200 per QALY relative to clopidogrel). Ticagrelor was the most effective strategy($52 600 per QALY relative to genotyping with ticagrelor).

RESULTS OF SENSITIVITY ANALYSIS:

Stronger associations between genotype and thrombotic outcomes rendered ticagrelor substantially less cost-effective ($104 800 per QALY). Genotyping with prasugrel was the preferred therapy among patients who could not tolerate ticagrelor.

LIMITATION:

No randomized trials have directly compared genotyping strategies or prasugrel with ticagrelor.

CONCLUSION:

Genotype-guided personalization may improve the cost-effectiveness of prasugrel and ticagrelor after percutaneous coronary intervention for ACS, but ticagrelor for all patients may bean economically reasonable alternative in some settings.

PMID:
24727840
DOI:
10.7326/M13-1999
[PubMed - indexed for MEDLINE]
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