A cost-effectiveness and safety analysis of dual antiplatelet therapy comparing aspirin–clopidogrel to aspirin–ticagrelor in patients with acute coronary syndrome

Abstract

Background: Dual antiplatelet therapy (DAPT) using either an aspirin–clopidogrel (A–C) combination or aspirin–ticagrelor (A–T) combination has become the standard therapy for acute coronary syndrome (ACS). Ticagrelor shows better pharmacokinetic profiles but is more expensive. This study aimed to compare cost-effectiveness and safety profiles of A–C versus A–T in patients with ACS.Methods: This was a retrospective cohort study of ACS patient at the Cipto Mangunkusumo Hospital between 2014 and 2016. ACS patients treated for the first time with A–T or A–C were included. Occurrence of major adverse cardiovascular events (MACE) within 3, 6, 9, and 12 months were used as effectiveness outcomes, while safety outcomes were measured based on the incidence of adverse drug reactions (major and minor bleeding, dyspnea, and hyperuricemia). Cost-effectiveness analysis was presented as incremental cost-effectiveness ratio (ICER).Results: Data records obtained from 123 ACS patients treated with A–C and 57 ACS patients treated with A–T were evaluated. Within the first three months, the MACE rate was 15.8% in the A–T group and 31.7% in the A–C group (RR: 0.498, 95% CI: 0.259–0.957, p=0.039). There was no statistically significant difference observed in the number of MACE between groups after 6, 9, and 12 months. The A–T group had a higher incidence of major bleeding (melena) than the A–C group (5.3% vs 1.62%, p=0.681), especially in geriatric patients. Minor bleeding was observed in three patients of the A–C group, but in none of the patients in the A–T group. The cost of ICER was IDR 279,438, indicating the additional cost needed for avoiding MACE within 3 months, if A–T was used.Conclusion: The aspirin–ticagrelor combination is a clinically superior and cost-effective option for MACE prevention among ACS patients, especially during the first three months of DAPT, with a slight but not significantly higher major bleeding risk when compared to the aspirin–clopidogrel combination.

Direct Medical Cost Inpatient ACS-STEMI at Sardjito Hospital 2017-2018

“…Table 3 shows that the use of the combination regimen was greater (81.6%) than the monotherapy regimen (18.4%). These results are in line with the study of Nafrialdi et al, (2018) which showed that the use of a combination therapy regimen of clopidogrel and aspirin in patients with ACS was greater (68.3%) compared to ticagrelor monotherapy (31.7%).…”

The role of clopidogrel resistance-related genetic and epigenetic factors in major adverse cardiovascular events among patients with acute coronary syndrome after percutaneous coronary intervention

“…However, the main conditions included in the MACE studies were angina pectoris, recurrent AMI, stroke, and death. The proportion of MACEs in previous studies showed different results (3,4,48) In this study, women marginally have a higher risk of developing MACEs than men. The proportion of women (7.5%) was smaller than that of men (92.5%), resulting in a higher risk of MACEs for women.…”

“…However, the main conditions included in the MACE studies were angina pectoris, recurrent AMI, stroke, and death. The proportion of MACEs in previous studies showed different results ( 3 , 4 , 48 ). Nafrialdi et al ( 3 ) found a proportion of 29.3% in post-PCI patients in the 3 months of observation.…”

“…The proportion of MACEs in previous studies showed different results ( 3 , 4 , 48 ). Nafrialdi et al ( 3 ) found a proportion of 29.3% in post-PCI patients in the 3 months of observation. Miao et al ( 4 ) and Mrdovic et al ( 48 ) demonstrated low proportions of 1.47 and 9.1% in 4 years and 30 days of observations, respectively.…”

“…Percutaneous coronary intervention (PCI) is a non-surgical revascularization method that is commonly performed to restore coronary blood flow (2). Patients undergoing PCI are still at risk of developing major adverse cardiac events (MACEs), such as recurrent angina pectoris, recurrent acute myocardial infarction (AMI), stroke, and death (3)(4)(5). A combination of aspirin and clopidogrel (dual antiplatelet therapy) has become a standard pharmacotherapeutic modality to prevent the onset and recurrence of ischemic events, thereby reducing MACEs (2,6).…”