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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.

journal_name

Ann Intern Med

journal_title

Annals of internal medicine

authors

Kazi DS,Garber AM,Shah RU,Dudley RA,Mell MW,Rhee C,Moshkevich S,Boothroyd DB,Owens DK,Hlatky MA

doi

10.7326/M13-1999

subject

Has Abstract

pub_date

2014-02-18 00:00:00

pages

221-32

issue

eissn

0003-4819

issn

1539-3704

pii

1829790

journal_volume

160

pub_type

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