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

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

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 be an economically reasonable alternative in some settings.