title: Cost-effectiveness of cytochrome P450 2C19 genotype screening for selection of antiplatelet therapy with clopidogrel or prasugrel.
abstract: OBJECTIVE
  To estimate the cost-effectiveness of genotype-guided selection of antiplatelet therapy compared with selecting clopidogrel or prasugrel irrespective of genotype.
  
  
  METHODS
  Decision model based on event occurrence in the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction (TRITON-TIMI) 38.
  
  
  METHODS
  Simulated cohort of patients with acute coronary syndrome scheduled to undergo percutaneous coronary intervention (PCI), consisting of three arms: those receiving genotype-guided antiplatelet therapy with clopidogrel or prasugrel, those receiving clopidogrel regardless of genotype, and those receiving prasugrel regardless of genotype.
  
  
  RESULTS
  All three arms of the model incorporated the probability that patients would experience a cardiovascular event (death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke), a bleeding event (major or minor bleeding), or no event while receiving antiplatelet therapy during the 15 months after the scheduled PCI. The cytochrome P450 (CYP) 2C19 genotype determined antiplatelet drug selection in the genotyping group. Cost-effectiveness was expressed as the incremental cost-effectiveness ratio (ICER) for each event avoided in the genotype-guided therapy arm versus the other two arms. Genotype-guided antiplatelet therapy was dominant, or more effective and less costly, when compared with the selection of clopidogrel (ICER -$6760 [95% confidence interval (CI) -$6720 to -$6790]) or prasugrel (ICER -$11,710 [95% CI -$11,480 to -$11,950]) for all patients without regard to genotype. Genotype-guided therapy that included generic clopidogrel was dominant to prasugrel for all patients (ICER -$27,160 [95% CI -$27,890 to -$26,420]). Cost savings were not evident when genotype-guided therapy that included generic clopidogrel was compared with generic clopidogrel for all patients (ICER $2300 [95% CI $2290 to $2320]). [Correction added after online publication 12-Mar-2012: In the previous sentence -$2300 has been corrected as $2300.].
  
  
  CONCLUSIONS
  Genotype-guided antiplatelet therapy selection may be more cost-effective and may provide more clinical value due to fewer adverse outcomes.
authors.affiliation: School of Pharmacy, University of Maryland, Baltimore, Maryland, USA. erees001@umaryland.edu
authors.forename: Emily S
authors.initials: ES
authors.lastname: Reese
authors.forename: C
authors.initials: C
authors.lastname: Daniel Mullins
authors.forename: Amber L
authors.initials: AL
authors.lastname: Beitelshees
authors.forename: Eberechukwu
authors.initials: E
authors.lastname: Onukwugha
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy; D001189:Aryl Hydrocarbon Hydroxylases / Q000235:genetics*; D002318:Cardiovascular Diseases / Q000188:drug therapy; D000077144:Clopidogrel; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D065731:Cytochrome P-450 CYP2C19; D003663:Decision Trees; D016568:Drugs, Generic / Q000191:economics; D005838:Genotype; D006470:Hemorrhage / Q000139:chemically induced / Q000191:economics; D006801:Humans; D018803:Models, Economic; D015233:Models, Statistical; D009203:Myocardial Infarction / Q000188:drug therapy; D010879:Piperazines / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D000068799:Prasugrel Hydrochloride; D013876:Thiophenes / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D015912:Thrombolytic Therapy / Q000191:economics*; D013988:Ticlopidine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use
chemical_list: D016568:Drugs, Generic; D010879:Piperazines; D010975:Platelet Aggregation Inhibitors; D013876:Thiophenes; D000077144:Clopidogrel; D001189:Aryl Hydrocarbon Hydroxylases; C045793:CYP2C19 protein, human; D065731:Cytochrome P-450 CYP2C19; D000068799:Prasugrel Hydrochloride; D013988:Ticlopidine