Abstract 12934: Universal Versus Platelet Reactivity Assay-Driven Use of P2Y12 Inhibitors in Acute Coronary Syndrome Patients: A Cost-Effectiveness Analysis From a United Kingdom Perspective
Background: On-treatment platelet reactivity assay (PRA) monitoring can accurately predict which patients will respond poorly to clopidogrel. We sought to determine the cost-effectiveness of universal ticagrelor or prasugrel compared to PRA-driven selection of dual antiplatelet therapy for acute coronary syndrome (ACS) patients living in the United Kingdom (UK).
Methods: A hybrid decision tree/Markov model was used to calculate 5-year costs (2013GBP£), quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) for 1-year of universal (given to all patients) ticagrelor or prasugrel compared to each agents’ corresponding PRA-driven strategy (ticagrelor or prasugrel given only to patients with high platelet reactivity (HPR) denoted by a value >208 on the VerifyNow P2Y12 assay, Accumetrics, San Diego, CA, others received generic clopidogrel). We assumed a cohort of 70-year-old ACS patients with a 42.7% incidence of HPR about 24-48 hours post-revascularization. The analysis was conducted from a UK National Health Service perspective and used a 1-year cycle length. Data depicting the efficacy and safety of ticagrelor, prasugrel and clopidogrel were taken from multinational randomized trials and adjusted based upon UK-specific epidemiologic data.
Results: Universal ticagrelor was not found to be cost-effective compared to its corresponding PRA-driven strategy (ICER=£36,600/QALY), and universal prasugrel was dominated by its PRA-driven strategy (universal prasugrel was $356 more expensive, but yielded 0.026 fewer QALYs). The model’s results were most sensitive to differences in antiplatelet agent costs and drug-specific relative risks of major adverse cardiac events. Monte Carlo simulation suggested universal ticagrelor or prasugrel use would only be cost-effective in 25% and 11% of 10,000 iterations compared to their respective PRA-driven strategies, assuming a willingness-to-pay threshold of £20,000/QALY.
Conclusion: Universal utilization of the new P2Y12 inhibitors is not likely to be cost-effective when compared to PRA-driven strategies. PRA-driven selection of dual antiplatelet therapy appears to be a reasonable strategy to decrease ACS-associated healthcare expenditures.
- © 2013 by American Heart Association, Inc.