lunes, 24 de febrero de 2014

Annals of Internal Medicine | Cost-Effectiveness of Genotype-Guided and Dual Antiplatelet Therapies in Acute Coronary Syndrome

Pharmacogenomics

Cost-effectiveness of genotype-guided and dual antiplatelet therapies in acute coronary syndrome

Kazi D, et al. Ann Intern Med. 2014;160(4):221-232-232

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Original Research | 18 February 2014

Cost-Effectiveness of Genotype-Guided and Dual Antiplatelet Therapies in Acute Coronary Syndrome

Dhruv S. Kazi, MD, MSc, MS; Alan M. Garber, MD, PhD; Rashmee U. Shah, MD, MS; R. Adams Dudley, MD, MBA; Matthew W. Mell, MD; Ceron Rhee, MBA; Solomon Moshkevich, MBA; Derek B. Boothroyd, PhD; Douglas K. Owens, MD; and Mark A. Hlatky, MD

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Ann Intern Med. 2014;160(4):221-232-232. doi:10.7326/M13-1999

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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.

Design: Decision-analytic model.

Data Sources: Published literature, Medicare claims, and life tables.

Target Population: Patients having percutaneous coronary intervention for ACS.

Time Horizon: Lifetime.

Perspective: Societal.

Intervention: 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.

Outcome Measures: Direct medical costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).

Results of Base-Case Analysis: 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 of Sensitivity Analysis: 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.

Limitation: No randomized trials have directly compared genotyping strategies or prasugrel with ticagrelor.

Conclusion: Genotype-guided personalization may improve the cost-effectiveness of prasugrel and ticagrelor after percutaneous coronary intervention for ACS, but ticagrelor for all patients may be an economically reasonable alternative in some settings.

Primary Funding Sources: American Heart Association, U.S. Department of Veterans Affairs, Stanford University, and University of California San Francisco.