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Purpose: To incorporate cost-effectiveness analysis (CEA) in formulary management recommendations for antiplatelets when used for secondary prevention of acute coronary syndrome (ACS).
Methods: Clopidogrel in combination with aspirin has been the standard ACS treatment option. Prasugrel and ticagrelor are new antiplatelet agents with comparative clinical trial data with clopidogrel. The Department of Defense (DoD) Pharmacy and Therapeutics (P&T) Committee considered both clinical and cost-effectiveness when determining the antiplatelet agents’ formulary placement. The clinical review noted prasugrel and ticagrelor are more effective than clopidogrel in reducing the composite endpoint of cardiovascular (CV) death, myocardial infarction (MI) and stroke. Compared to clopidogrel, prasugrel confers a higher bleeding risk than clopidogrel, while ticagrelor exhibits a similar bleeding risk. Two separate CE models were constructed for the antiplatelet cost analyses: prasugrel versus clopidogrel and ticagrelor versus clopidogrel. Analysis was based on direct comparisons of relevant ACS clinical trial data. The models compared the annual cost per CV event avoided (the composite of nonfatal MI, nonfatal stroke, and death from CV cause).
Results: CEA results showed that prasugrel and ticagrelor provide reasonable clinical benefit for the increase in treatment cost, as shown by their incremental cost-effectiveness ratios (ICERs) of $28,083 and $58,358 per cardiovascular event avoided, respectively. For both analyses, variation in the relative rates of MI and CV death and corresponding costs had the greatest impact on the ICER.
Conclusion: Ticagrelor or prasugrel may be cost-effective options for ACS in place of clopidogrel. However, clopidogrel remains the preferred antiplatelet agent in DoD, due to wider clinical utility than the newer agents, and the significant price reduction occurring with recent patent loss.