Cost-effectiveness of clopidogrel, prasugrel and ticagrelor for dual antiplatelet therapy after acute coronary syndrome: a decision-analytic model

Abstract

Background: The use of prasugrel or ticagrelor as part of dual antiplatelet therapy with acetylsalicylic acid after acute coronary syndrome (ACS) improves clinical outcomes relative to clopidogrel. The relative cost-effectiveness of these agents are unknown. We conducted an economic analysis evaluating 12 months of treatment with clopidogrel, prasugrel or ticagrelor after ACS. Methods:We developed a fully probabilistic Markov cohort decision-analytic model using a lifetime horizon, from the perspective of the Ontario Ministry of Health and Long-Term Care. The model incorporated risks of death, recurrent ACS, heart failure, major bleeding and other adverse effects of treatment. Data on probabilities and utilities were obtained from the published literature where available. The primary outcome was quality-adjusted life-years (QALYs).Results: Treatment with clopidogrel was associated with the lowest effectiveness (7.41 QALYs, 95% confidence interval [CI] 1.05-14.79) and the lowest cost ($39 601, 95% CI $8434-$111 186). Ticagrelor treatment had an effectiveness of 7.50 QALYs (95% CI 1.13-14.84) at a cost of $40 649 (95% CI $9327-$111 881). The incremental cost-effectiveness ratio (ICER) for ticagrelor relative to clopidogrel was $12 205 per QALY gained. Prasugrel had an ICER of $57 630 per QALY gained relative to clopidogrel. Ticagrelor was the preferred option in 90% of simulations at a willingness-to-pay threshold of $50 000 per QALY gained. Interpretation:Ticagrelor was the most cost-effective agent when used as part of dual antiplatelet therapy after ACS. This conclusion was robust to wide variations in model parameters. AbstractResearch CMAJ OPEN CMAJ OPEN, 3(4) E439

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

“…Both have demonstrated superior efficacy compared with clopidogrel, albeit without prospective genotype substratification and at increased bleeding risk and higher medication costs [2]. Clinical trial results have also informed cost-effectiveness analysis (CEA) of alternative antiplatelets versus clopidogrel [9][10][11][12] and of CYP2C19 genotype-guided DAPT [13][14][15].…”

Appropriate utilization of cardiac computed tomography for the assessment of stable coronary artery disease

“…Finally, traditional cost-effectiveness modelling was not appropriate for the design of this study. However, we used cost estimations using methods similar to those utilized in prior similar studies [ 19 , 26 ]. Nonetheless, it is important to state that the cost savings reported in our study are estimates and not based on exact data (for example, the number of CCTAs performed annually in the United States is an estimated number because the exact number is not known).…”

Cost-Effectiveness Analysis of Cardiovascular Disease Treatment in Japan

“…A Canadian study showed an ICER of $57,630 per QALY for prasugrel over clopidogrel. 21) In a study in Japan, the ICER of cilostazol over aspirin for secondary prevention of cerebral infarction was 1,800,000 yen per QLAY, 22) which suggested that cilostazol was cost-effective for secondary prevention of cerebral infarction in Japan.…”