Cost Effectiveness of a CYP2C19 Genotype-Guided Strategy in Patients with Acute Myocardial Infarction: Results from the POPular Genetics Trial

Abstract

IntroductionThe POPular Genetics trial demonstrated that a CYP2C19 genotype-guided P2Y 12 inhibitor strategy reduced bleeding rates compared with standard treatment with ticagrelor or prasugrel without increasing thrombotic event rates after primary percutaneous coronary intervention (PCI). Objective In this analysis, we aimed to evaluate the cost effectiveness of a genotype-guided strategy compared with standard treatment with ticagrelor or prasugrel. Methods A 1-year decision tree based on the POPular Genetics trial in combination with a lifelong Markov model was developed to compare costs and quality-adjusted life-years (QALYs) between a genotype-guided and a standard P2Y 12 inhibitor strategy in patients with myocardial infarction undergoing primary PCI. The cost-effectiveness analysis was conducted from a Dutch healthcare system perspective. Within-trial survival and utility data were combined with lifetime projections to evaluate lifetime cost effectiveness for a cohort of 1000 patients. Costs and utilities were discounted at 4 and 1.5%, respectively, according to Dutch guidelines for health economic studies. Besides deterministic and probabilistic sensitivity analyses, several scenario analyses were also conducted (different time horizons, different discount rates, equal prices for P2Y 12 inhibitors, and equal distribution of thrombotic events between the two strategies). Results Base-case analysis with a hypothetical cohort of 1000 subjects demonstrated 8.98 QALYs gained and €725,550.69 in cost savings for the genotype-guided strategy (dominant). The deterministic and probabilistic sensitivity analysis confirmed the robustness of the model and the cost-effectiveness results. In scenario analyses, the genotype-guided strategy remained dominant. ConclusionIn patients undergoing primary PCI, a CYP2C19 genotype-guided strategy compared with standard treatment with ticagrelor or prasugrel resulted in QALYs gained and cost savings. Trial Registration Clinicaltrials.gov number: NCT01761786, Netherlands trial register number: NL2872 Pim W. M. van Dorst, Gerrit J. A. Vos have contributed equally to this work.

The Clinical Implementation of CYP2C19 Genotyping in Patients with an Acute Coronary Syndrome: Insights From the FORCE-ACS Registry

“…By applying a genotype-guided strategy in ACS patients treated with ticagrelor or prasugrel, 60-70% of patients can be de-escalated to clopidogrel, which results in reduced side effects and lower costs. [28][29][30] Our findings match the POPular Genetics trial costeffectiveness analyses. 29 This study showed that a de-escalation strategy has the potential to yield cost savings of more than €300 per patient in the first year after ACS.…”

Feasibility of Community Pharmacist-Initiated and Point-of-Care CYP2C19 Genotype-Guided De-Escalation of Oral P2Y12 Inhibitors

“…For testing to be cost saving, the de-escalation rate needs to improve (from 20% to at least 40%), and/or the duration of treatment impact would have to increase (for example by testing earlier or testing only chronic users). Earlier studies on genotype-guided P2Y 12 inhibitor therapy selection showed cost-effectiveness based on the premise of a 100% de-escalation rate [ 67 , 68 , 69 , 70 ]. This assumption has been deemed unrealistic, but our study shows that less than 100% de-escalation can still suffice to obtain cost savings.…”

Genotype-Guided Use of P2Y12 Inhibitors: A Review of Current State of the Art

“…Out of the 13 included studies, only two studies showed that universal ticagrelor was cost-effective when compared to genotype-guided therapy. They concluded that genotype-guided therapy is cost-effective in patients with ACS undergoing PCI ( 96 , 97 ). Most recently, Claassens et al conducted a cost effectiveness analysis of genotype guided therapy based on the POPular Genetics trial ( 97 ).…”

“…They concluded that genotype-guided therapy is cost-effective in patients with ACS undergoing PCI ( 96 , 97 ). Most recently, Claassens et al conducted a cost effectiveness analysis of genotype guided therapy based on the POPular Genetics trial ( 97 ). A base-case analysis was performed for a cohort of 1,000 patients showed that genotype guided therapy was dominant, and resulted in a gain of 8.98 QALYs, and cost saving of €725,550.69 when compared to universal ticagrelor or prasugrel ( 97 ).…”