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

  • Author(s): Kazi, Dhruv S
  • Garber, Alan M
  • Shah, Rashmee U
  • Dudley, R Adams
  • Mell, Matthew W
  • Rhee, Ceron
  • Moshkevich, Solomon
  • Boothroyd, Derek B
  • Owens, Douglas K
  • Hlatky, Mark A
  • et al.

Published Web Location

https://doi.org/10.7326/m13-1999Creative Commons Attribution 4.0 International Public License
Abstract

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.To determine the most cost-effective strategy for dual antiplatelet therapy after percutaneous coronary intervention for ACS.Decision-analytic model.Published literature, Medicare claims, and life tables.Patients having percutaneous coronary intervention for ACS.Lifetime.Societal.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.Direct medical costs, quality-adjusted life years(QALYs), and incremental cost-effectiveness ratios (ICERs).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).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.No randomized trials have directly compared genotyping strategies or prasugrel with ticagrelor.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.

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