title: Universal versus platelet reactivity assay-driven use of P2Y12 inhibitors in acute coronary syndrome patients: cost-effectiveness analyses for six European perspectives.
abstract: Platelet reactivity assays (PRAs) can predict patients' likely response to clopidogrel. As ticagrelor and prasugrel are typically considered first-line agents for acute coronary syndrome in Europe, we assessed the cost-effectiveness of universal compared to PRA-driven selection of these agents. A Markov model was used to calculate five-year costs (2013£/€), quality-adjusted life-years and incremental cost-effectiveness ratios (ICERs) for one-year of universal ticagrelor or prasugrel (given to all) compared to each agents' corresponding PRA-driven strategy (ticagrelor/prasugrel in those with high platelet reactivity [HPR, >208 on the VerifyNow P2Y12 assay], others given generic clopidogrel). We assumed patients had their index event at 65-70 years of age and had a 42.7% incidence of HPR 24-48 hours post-revascularisation. The analysis was conducted from the perspective of six countries (France, Germany, Italy, Spain, the Netherlands and United Kingdom) and used a one-year cycle length. Event data for P2Y12 inhibitors were taken from multinational randomised trials and adjusted using country-specific epidemiologic data. Neither universal ticagrelor nor prasugrel were found to be cost-effective (all ICERs >40,250€ or £36,600/QALY) compared to their corresponding PRA-driven strategies in any of the countries evaluated. Results were sensitive to differences in P2Y12 Inhibitors costs and drug-specific relative risks of major adverse cardiac events. Monte Carlo simulation suggested universal ticagrelor or prasugrel were cost-effective in only 25-44% and 11-17% of 10,000 iterations compared to their respective PRA-driven strategies, when applying a willingness-to-pay threshold = €30,000 or £20,000/QALY. In conclusion, the universal use of newer P2Y12 inhibitors is not likely cost-effective compared to PRA-driven strategies.
authors.affiliation: Craig I. Coleman, PharmD, Professor, University of Connecticut, Hartford Hospital/University of Connecticut, Evidence-Based Practice Center, 80 Seymour Street, Hartford, CT 06102-5037, USA, Tel.: +1 860 545 2096, Fax: +1 860 545 2277, E-mail: craig.colema@hhchealth.org.
authors.forename: Craig I
authors.initials: CI
authors.lastname: Coleman
authors.forename: Brendan L
authors.initials: BL
authors.lastname: Limone
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy* / Q000191:economics*; D000241:Adenosine / Q000031:analogs & derivatives / Q000191:economics / Q000627:therapeutic use; D000368:Aged; D001780:Blood Coagulation Tests; D001792:Blood Platelets / Q000187:drug effects*; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D005060:Europe; D006801:Humans; D015994:Incidence; D008390:Markov Chains; D055118:Medication Adherence; D009010:Monte Carlo Method; D010879:Piperazines / Q000191:economics / Q000627:therapeutic use; D010975:Platelet Aggregation Inhibitors / Q000191:economics / Q000627:therapeutic use; D000068799:Prasugrel Hydrochloride; D058921:Purinergic P2Y Receptor Antagonists / Q000191:economics / Q000627:therapeutic use*; D019057:Quality-Adjusted Life Years; D058925:Receptors, Purinergic P2Y12 / Q000378:metabolism*; D013876:Thiophenes / Q000191:economics / Q000627:therapeutic use; D000077486:Ticagrelor
chemical_list: C548576:P2RY12 protein, human; D010879:Piperazines; D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists; D058925:Receptors, Purinergic P2Y12; D013876:Thiophenes; D000068799:Prasugrel Hydrochloride; D000077486:Ticagrelor; D000241:Adenosine
keywords: Markov model; Platelet reactivity assay; acute coronary syndrome; antiplatelet agents; cost-effectiveness analysis