Cost-effectiveness Analysis of Genotype-guided Antiplatelet Therapy in Patients with Acute Coronary Syndrome and Planned Percutaneous Coronary Intervention

Purpose: Prasugrel-based therapy is recommended over clopidogrel-based therapy in poor/intermediate CYP2C19 metabolizers with acute coronary syndrome (ACS) and planned percutaneous coronary intervention (PCI). CYP2C19 genetic test, therefore, can be utilized to guide antiplatelet therapy in ACS patients. The purpose of this study was to evaluate the cost-effectiveness of the genotype-guided treatment approach, as compared with prasugrel and generic clopidogrel treatment irrespective of genotype, in ACS/PCI patients from the US healthcare provider’s perspective.

Methods: A decision analytic model was developed to project the lifetime economic and humanistic burden associated with clinical outcomes (including myocardial infarction [MI], stroke and major bleeding) for the three strategies in ACS/PCI patients. Probabilities of outcomes were obtained from the TRITON-TIMI 38 trial comparing prasugrel and clopidogrel; costs (adjusted to 2011 US dollars), age-adjusted quality of life, and disutilities were identified through systematic literature review. Incremental cost-effectiveness ratio (ICER) was calculated for the treatment strategies, with quality-adjusted life years (QALYs) as the primary effectiveness outcome. One-way and probabilistic sensitivity analyses were performed to assess the robustness of the results.

Results: Genotype-guided therapy was the most cost-effective strategy in the base-case analysis. Clopidogrel cost $19,763 and provided 10.0308 QALYs versus prasugrel ($22,886, 10.0353 QALYs) and genotype-guided therapy ($20,104, 10.0517 QALYs). The incremental cost per QALY gained with genotype-guided therapy compared with clopidogrel was $16,265. Prasugrel therapy was dominated by the genotype-guided strategy. Results were sensitive to the cost of prasugrel, cost of clopidogrel, and cost of MI. Acceptability curve showed that genotype-guided therapy had at least 77% likelihood of being more cost-effective than clopidogrel at willingness-to-pay (WTP) of $100,000/QALY. In comparison with prasugrel, genotype-guided therapy was more cost-effective with > 80% certainty at all WTP thresholds.

Conclusion: Our modeling analyses suggest that genotype-guided therapy is a cost-effective strategy in patients with ACS undergoing PCI.