title: Cost-Effectiveness Analysis of Ticagrelor and Prasugrel for the Treatment of Acute Coronary Syndrome.
abstract: BACKGROUND
  In the management of Asian patients with acute coronary syndrome (ACS), the comparative cost-effectiveness of ticagrelor and prasugrel, referenced to generic clopidogrel, is unknown.
  
  
  OBJECTIVE
  To assess the cost-effectiveness of ticagrelor and prasugrel as compared with generic clopidogrel in patients with ACS in Singapore.
  
  
  METHODS
  A Markov model simulating a typical cohort of 62-year-old patients with ACS was constructed from a patient's perspective over a lifetime horizon. Treatment effects and adverse events, including nonfatal myocardial infarction, major bleeding related to non-coronary artery bypass grafting, dyspnea, or death, were estimated from pivotal trials comparing clopidogrel with ticagrelor and prasugrel, respectively. Costs were estimated from a tertiary hospital with more than 1500 admissions for ACS per year.
  
  
  RESULTS
  The incremental cost-effectiveness ratio (ICER) per life-year gained for ticagrelor was about three times more favorable than for prasugrel (Singapore dollar [SGD] 13,276 vs. SGD 38,809). The ICER per quality-adjusted life-year (QALY) for prasugrel and ticagrelor, however, was comparable at SGD 18,921 and SGD 18,647, respectively. Deterministic sensitivity analysis revealed that the ICER per QALY gained for prasugrel and ticagrelor was most sensitive to the hazard ratio of all-cause mortality and utility for dyspnea, respectively. Probabilistic sensitivity analysis demonstrated that compared with clopidogrel, the probabilities of prasugrel and ticagrelor being cost-effective are 87.1% and 88.3% based on the willingness-to-pay value of SGD 65,000 (one time the gross domestic product per capita in Singapore).
  
  
  CONCLUSIONS
  Ticagrelor is more cost-effective than prasugrel in reducing all-cause mortality in patients with ACS. The cost-effectiveness of ticagrelor and prasugrel become similar, however, when accounting for the impact of dyspnea on QALY.
authors.affiliation: Pharmacy & Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore. Electronic address: Ying_Jiao_Zhao@nhg.com.sg.
authors.forename: Ying Jiao
authors.initials: YJ
authors.lastname: Zhao
authors.affiliation: Pharmacy & Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore.
authors.forename: Ai Leng
authors.initials: AL
authors.lastname: Khoo
authors.affiliation: Pharmacy & Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore.
authors.forename: Liang
authors.initials: L
authors.lastname: Lin
authors.affiliation: Pharmacy & Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore.
authors.forename: Monica
authors.initials: M
authors.lastname: Teng
authors.affiliation: Pharmacy Department, National University Health System, Singapore.
authors.forename: Tuck Seng
authors.initials: TS
authors.lastname: Wu
authors.affiliation: Cardiac Department, National University Heart Centre, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Mark Y
authors.initials: MY
authors.lastname: Chan
authors.affiliation: Pharmacy & Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore.
authors.forename: Boon Peng
authors.initials: BP
authors.lastname: Lim
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy*; D000241:Adenosine / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000191:economics* / Q000627:therapeutic use; D000068799:Prasugrel Hydrochloride / Q000191:economics* / Q000627:therapeutic use; D012846:Singapore; D000077486:Ticagrelor
chemical_list: D010975:Platelet Aggregation Inhibitors; D000068799:Prasugrel Hydrochloride; D000077486:Ticagrelor; D000241:Adenosine
keywords: antiplatelet; clopidogrel; cost-effectiveness; prasugrel; ticagrelor