title: Ticagrelor versus genotype-driven antiplatelet therapy for secondary prevention after acute coronary syndrome: a cost-effectiveness analysis.
abstract: BACKGROUND
  Clopidogrel's effectiveness is likely reduced significantly for prevention of thrombotic events after acute coronary syndrome (ACS) in patients exhibiting a decreased ability to metabolize clopidogrel into its active form. A genetic mutation responsible for this reduced effectiveness is detectable by genotyping. Ticagrelor is not dependent on gene-based metabolic activation and demonstrated greater clinical efficacy than clopidogrel in a recent secondary prevention trial. In 2011, clopidogrel will lose its patent protection and likely will be substantially less expensive than ticagrelor.
  
  
  OBJECTIVE
  To determine the cost-effectiveness of ticagrelor compared with a genotype-driven selection of antiplatelet agents.
  
  
  METHODS
  A hybrid decision tree/Markov model was used to estimate the 5-year medical costs (in 2009 US$) and outcomes for a cohort of ACS patients enrolled in Medicare receiving either genotype-driven or ticagrelor-only treatment. Outcomes included life years and quality-adjusted life years (QALYs) gained. Data comparing the clinical performance of ticagrelor and clopidogrel were derived from the Platelet Inhibition and Patient Outcomes trial.
  
  
  RESULTS
  The incremental cost-effectiveness ratio (ICER) for universal ticagrelor was $10,059 per QALY compared to genotype-driven treatment, and was most sensitive to the price of ticagrelor and the hazard ratio for death for ticagrelor compared with clopidogrel. The ICER remained below $50,000 per QALY until a monthly ticagrelor price of $693 or a 0.93 hazard ratio for death for ticagrelor relative to clopidogrel. In probabilistic analyses, universal ticagrelor was below $50,000 per QALY in 97.7% of simulations.
  
  
  CONCLUSIONS
  Prescribing ticagrelor universally increases quality-adjusted life years for ACS patients at a cost below a typically accepted threshold.
authors.affiliation: Department of Health Policy and Management, University of North Carolina, Chapel Hill, NC, USA.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Crespin
authors.forename: Jerome J
authors.initials: JJ
authors.lastname: Federspiel
authors.forename: Andrea K
authors.initials: AK
authors.lastname: Biddle
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Jonas
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Rossi
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy / Q000191:economics* / Q000517:prevention & control; D000241:Adenosine / Q000008:administration & dosage / Q000031:analogs & derivatives* / Q000191:economics; D000368:Aged; D000369:Aged, 80 and over; D003362:Cost-Benefit Analysis / Q000191:economics; D005838:Genotype; D006801:Humans; D008390:Markov Chains; D006278:Medicare / Q000191:economics; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000191:economics*; D055502:Secondary Prevention / Q000191:economics*; D000077486:Ticagrelor; D014481:United States
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077486:Ticagrelor; D000241:Adenosine