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

被引:35
作者
Limdi, Nita A. [1 ]
Cavallari, Larisa H. [2 ,3 ]
Lee, Craig R. [4 ]
Hillegass, William B. [5 ,6 ]
Holmes, Ann M. [7 ]
Skaar, Todd C. [8 ]
Pisu, Maria [9 ]
Dillon, Chrisly [1 ]
Beitelshees, Amber L. [10 ,11 ]
Empey, Philip E. [12 ]
Duarte, Julio D. [2 ,3 ]
Diaby, Vakaramoko [13 ]
Gong, Yan [2 ,3 ]
Johnson, Julie A. [2 ,3 ]
Graves, John [14 ]
Garbett, Shawn [14 ]
Zhou, Zilu [14 ]
Peterson, Josh F. [14 ]
机构
[1] Univ Alabama Birmingham, Dept Neurol, UAB Stn, Birmingham, AL 35294 USA
[2] Univ Florida, Dept Pharmacotherapy & Translat Res, Gainesville, FL USA
[3] Univ Florida, Ctr Pharmacogen, Gainesville, FL USA
[4] Univ N Carolina, Eshelman Sch Pharm, Div Pharmacotherapy & Expt Therapeut, Chapel Hill, NC 27515 USA
[5] Univ Mississippi, Med Ctr, Dept Data Sci, Jackson, MS 39216 USA
[6] Univ Mississippi, Med Ctr, Dept Med, Jackson, MS 39216 USA
[7] Indiana Univ Purdue Univ, Indianapolis, IN 46202 USA
[8] Indiana Univ, Indianapolis, IN 46204 USA
[9] Univ Alabama Birmingham, Div Prevent Med, Birmingham, AL USA
[10] Univ Maryland, Dept Med, Baltimore, MD 21201 USA
[11] Univ Maryland, Program Personalized & Genom Med, Baltimore, MD 21201 USA
[12] Univ Pittsburgh, Sch Pharm, Dept Pharm & Therapeut, Ctr Clin Pharmaceut Sci, Pittsburgh, PA 15261 USA
[13] Univ Florida, Coll Pharm, Dept Pharmaceut Outcomes & Policy, Gainesville, FL USA
[14] Vanderbilt Univ, Med Ctr, Dept Biomed Informat, Nashville, TN USA
基金
美国国家卫生研究院;
关键词
TIMI; 38; TRIAL; CARDIOVASCULAR EVENTS; SECONDARY PREVENTION; RECEPTOR INHIBITORS; PLATELET INHIBITION; STENT THROMBOSIS; CLOPIDOGREL; GENOTYPE; OUTCOMES; TICAGRELOR;
D O I
10.1038/s41397-020-0162-5
中图分类号
Q3 [遗传学];
学科分类号
071007 ; 090102 ;
摘要
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.
引用
收藏
页码:724 / 735
页数:12
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