Cost-effectiveness of CYP2C19-guided antiplatelet therapy in patients with acute coronary syndrome and percutaneous coronary intervention informed by real-world data.

Pharmacogenomics J 2020 Feb 11. Epub 2020 Feb 11.

Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.

Current guidelines recommend dual antiplatelet therapy (DAPT) consisting of aspirin and a P2Y12 inhibitors following percutaneous coronary intervention (PCI). CYP2C19 genotype can guide DAPT selection, prescribing ticagrelor or prasugrel for loss-of-function (LOF) allele carriers (genotype-guided escalation). Cost-effectiveness analyses (CEA) are traditionally grounded in clinical trial data. We conduct a CEA using real-world data using a 1-year decision-analytic model comparing primary strategies: universal empiric clopidogrel (base case), universal ticagrelor, and genotype-guided escalation. We also explore secondary strategies commonly implemented in practice, wherein all patients are prescribed ticagrelor for 30 days post PCI. After 30 days, all patients are switched to clopidogrel irrespective of genotype (nonguided de-escalation) or to clopidogrel only if patients do not harbor an LOF allele (genotype-guided de-escalation). Compared with universal clopidogrel, both universal ticagrelor and genotype-guided escalation were superior with improvement in quality-adjusted life years (QALY's). Only genotype-guided escalation was cost-effective ($42,365/QALY) and demonstrated the highest probability of being cost-effective across conventional willingness-to-pay thresholds. In the secondary analysis, compared with the nonguided de-escalation strategy, although genotype-guided de-escalation and universal ticagrelor were more effective, with ICER of $188,680/QALY and $678,215/QALY, respectively, they were not cost-effective. CYP2C19 genotype-guided antiplatelet prescribing is cost-effective compared with either universal clopidogrel or universal ticagrelor using real-world implementation data. The secondary analysis suggests genotype-guided and nonguided de-escalation may be viable strategies, needing further evaluation.

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41397-020-0162-5DOI Listing
February 2020

Publication Analysis

Top Keywords

genotype-guided escalation
16
universal ticagrelor
16
nonguided de-escalation
12
genotype-guided
8
lof allele
8
real-world data
8
coronary intervention
8
genotype-guided de-escalation
8
secondary analysis
8
clopidogrel universal
8
universal clopidogrel
8
compared universal
8
percutaneous coronary
8
ticagrelor genotype-guided
8
antiplatelet therapy
8
universal
7
ticagrelor
6
clopidogrel
5
de-escalation
5
de-escalation strategy
4

References

(Supplied by CrossRef)

SD Wiviott et al.
N Engl J Med 2007

L Wallentin et al.
N Engl J Med 2009

EJ Benjamin et al.
Circulation 2018

GN Levine et al.
Circulation 2016

W Fan et al.
Am J Cardiol 2016

JL Mega et al.
J Am Med Assoc 2010

JL Mega et al.
Circulation 2009

L Wallentin et al.
Lancet 2010

H Abdel-Qadir et al.
CMAJ Open 2015

WE Wang et al.
J Thromb Thrombolysis 2014

D Liew et al.
Clin Ther 2013

Similar Publications