title: Cost-effectiveness of genotype-guided and dual antiplatelet therapies in acute coronary syndrome.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  To determine the most cost-effective strategy for dual antiplatelet therapy after percutaneous coronary intervention for ACS.
  
  
  METHODS
  Decision-analytic model.
  
  
  METHODS
  Published literature, Medicare claims, and life tables.
  
  
  METHODS
  Patients having percutaneous coronary intervention for ACS.
  
  
  METHODS
  Lifetime.
  
  
  CONCLUSIONS
  Societal.
  
  
  METHODS
  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.
  
  
  METHODS
  Direct medical costs, quality-adjusted life years(QALYs), and incremental cost-effectiveness ratios (ICERs).
  
  
  RESULTS
  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).
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  No randomized trials have directly compared genotyping strategies or prasugrel with ticagrelor.
  
  
  CONCLUSIONS
  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.
authors.forename: Dhruv S
authors.initials: DS
authors.lastname: Kazi
authors.forename: Alan M
authors.initials: AM
authors.lastname: Garber
authors.forename: Rashmee U
authors.initials: RU
authors.lastname: Shah
authors.forename: R Adams
authors.initials: RA
authors.lastname: Dudley
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Mell
authors.forename: Ceron
authors.initials: C
authors.lastname: Rhee
authors.forename: Solomon
authors.initials: S
authors.lastname: Moshkevich
authors.forename: Derek B
authors.initials: DB
authors.lastname: Boothroyd
authors.forename: Douglas K
authors.initials: DK
authors.lastname: Owens
authors.forename: Mark A
authors.initials: MA
authors.lastname: Hlatky
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy* / Q000601:surgery; D000241:Adenosine / Q000009:adverse effects / Q000031:analogs & derivatives / Q000191:economics / Q000627:therapeutic use; D000483:Alleles; D001189:Aryl Hydrocarbon Hydroxylases / Q000235:genetics; D000077144:Clopidogrel; D003328:Coronary Thrombosis / Q000517:prevention & control; D003362:Cost-Benefit Analysis; D065731:Cytochrome P-450 CYP2C19; D003661:Decision Support Techniques; D004180:Direct Service Costs; D004359:Drug Therapy, Combination; D016568:Drugs, Generic / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D005838:Genotype; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D062645:Percutaneous Coronary Intervention; D010879:Piperazines / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D011110:Polymorphism, Genetic; D000068799:Prasugrel Hydrochloride; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D013876:Thiophenes / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D000077486:Ticagrelor; 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; D000077486:Ticagrelor; D000241:Adenosine; D013988:Ticlopidine