title: Cost-effectiveness of universal and platelet reactivity assay-driven antiplatelet therapy in acute coronary syndrome.
abstract: Assays monitoring P2Y12 platelet reactivity can accurately predict which patients will have a poor response to clopidogrel. We sought to determine the cost-effectiveness of using platelet reactivity assays (PRAs) to select a dual-antiplatelet regimen for patients with acute coronary syndrome. A hybrid decision tree Markov model was developed to determine the cost-effectiveness of universal clopidogrel, ticagrelor, or prasugrel (given to all patients) or PRA-driven ticagrelor or prasugrel (given to patients with high platelet reactivity, defined as >230 on the VerifyNow P2Y12 assay; the others received generic clopidogrel). We assumed a cohort of 65-year-old patients with acute coronary syndrome and an incidence of high platelet reactivity of 32% and 13% at ~24 to 48 hours after revascularization and 1 month, respectively. The 5-year costs, quality-adjusted life-years, and incremental cost-effectiveness ratios were calculated for PRA-driven ticagrelor and prasugrel compared with universal clopidogrel, ticagrelor, or prasugrel. PRA-driven ticagrelor and prasugrel were cost-effective compared with universal clopidogrel (incremental cost-effectiveness ratio $40,100 and $49,143/quality-adjusted life-year, respectively); however, universal ticagrelor and prasugrel were not (incremental cost-effectiveness ratio $61,651 and $96,261/quality-adjusted life-year, respectively). Monte Carlo simulation suggested PRA-driven ticagrelor, PRA-driven prasugrel, universal ticagrelor, and universal prasugrel would have an incremental cost-effectiveness ratio <$50,000/quality-adjusted life-year in 52%, 40%, 23%, and 2% of the iterations compared with universal clopidogrel, respectively. Universal ticagrelor and prasugrel were not cost-effective compared with their respective PRA-driven regimens (incremental cost-effectiveness ratio $68,182; $116,875/quality-adjusted life-year, respectively). Monte Carlo simulation suggested universal ticagrelor and prasugrel would have an incremental cost-effectiveness ratio <$50,000/quality-adjusted life-year in 26% and 4% of iterations compared with their respective PRA-driven regimens. The results were most sensitive to differences in agent costs and drug-specific relative risks of death. In conclusion, even with generic clopidogrel, PRA-driven selection of antiplatelet therapy appeared to be a cost-effective strategy with the potential to decrease the overall acute coronary syndrome-associated healthcare costs.
authors: University of Connecticut School of Pharmacy, Storrs, CT, USA. ccolema@harthosp.org
authors: Craig I
authors: CI
authors: Coleman
authors: Brendan L
authors: BL
authors: Limone
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy* / Q000191:economics* / Q000401:mortality; D000241:Adenosine / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use; D000368:Aged; D000077144:Clopidogrel; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D004305:Dose-Response Relationship, Drug; D016527:Drug Costs / Q000706:statistics & numerical data; D004359:Drug Therapy, Combination / Q000191:economics; D016568:Drugs, Generic / Q000191:economics / Q000627:therapeutic use; D005260:Female; D006801:Humans; D008297:Male; D008390:Markov Chains; D009204:Myocardial Revascularization / Q000191:economics; D010879:Piperazines / Q000191:economics* / Q000627:therapeutic use*; D010975:Platelet Aggregation Inhibitors / Q000191:economics* / Q000627:therapeutic use*; D010979:Platelet Function Tests / Q000191:economics*; D000068799:Prasugrel Hydrochloride; D019057:Quality-Adjusted Life Years; D058925:Receptors, Purinergic P2Y12 / Q000097:blood* / Q000187:drug effects; D015996:Survival Rate; D013876:Thiophenes / Q000191:economics* / Q000627:therapeutic use*; D000077486:Ticagrelor; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use
chemical_list: D016568:Drugs, Generic; C548576:P2RY12 protein, human; D010879:Piperazines; D010975:Platelet Aggregation Inhibitors; D058925:Receptors, Purinergic P2Y12; D013876:Thiophenes; D000077144:Clopidogrel; D000068799:Prasugrel Hydrochloride; D000077486:Ticagrelor; D000241:Adenosine; D013988:Ticlopidine