Cost-Effectiveness of Genotype-Guided and Dual Antiplatelet Therapies in Acute Coronary Syndrome

Abstract

Genotype-guided personalization may improve the cost-effectiveness of prasugrel and ticagrelor after percutaneous coronary intervention for ACS, but ticagrelor for all patients may bean economically reasonable alternative in some settings.

Financial Analysis of CYP2C19 Genotyping in Patients Receiving Dual Antiplatelet Therapy Following Acute Coronary Syndrome and Percutaneous Coronary Intervention

“…Financial Analysis of CYP2C19 Genotyping in Patients Receiving Dual Antiplatelet Therapy Following Acute Coronary Syndrome and Percutaneous Coronary Intervention genotype-guided therapy was the most cost-effective strategy provided the cost of genotyping did not exceed $358 based on a willingness-to-pay threshold of $50,000 per quality-adjusted life-year. 8 Additional cost-effectiveness analyses support that CYP2C19 genotype-guided therapy has economic benefits resulting from savings because of prevention of avoidable adverse cardiac events. 8,10,11 Although cost-effectiveness of CYP2C19 genotype-guided antiplatelet therapy has been investigated, an opportunity to predict economic impact within managed care organizations remains.…”

“…8 Additional cost-effectiveness analyses support that CYP2C19 genotype-guided therapy has economic benefits resulting from savings because of prevention of avoidable adverse cardiac events. 8,10,11 Although cost-effectiveness of CYP2C19 genotype-guided antiplatelet therapy has been investigated, an opportunity to predict economic impact within managed care organizations remains. The objective of this investigation was to model the financial impact of CYP2C19 genotyping in ACS patients undergoing PCI and treated with clopidogrel, prasugrel, or ticagrelor in addition to aspirin within such an environment.…”

“…3,5 Despite the demonstrated association between the CYP2C19 genotype and improved clinical outcomes from antiplatelet therapy use, lingering barriers limit widespread use, including health care provider knowledge gaps, genotyping costs, and lack of uniform reimbursement for pharmacogenomic testing. 8 Lack of uniform coverage and reimbursement for pharmacogenetic testing is another significant barrier to clinical implementation along with cost-effectiveness of genotyping. While several large organizations (e.g., the Personalized Medicine Coalition) continue to advocate for this testing, it is uncertain whether the current payer systems are ideally prepared to assess clinical utility for pharmacogenomic applications or next-generation sequencing.…”

“…9 Several published studies have evaluated the cost-effectiveness of CYP2C19 genotyping for individualized antiplatelet therapy; however, opportunities to demonstrate favorable economic impact in different types of health systems exist. 8,10,11 A recent investigation by Kazi et al (2014) evaluated the cost-effectiveness of CYP2C19 genotype-guided antiplatelet therapy for patients with acute coronary syndrome (ACS) using a Markov model to evaluate 5 possible scenarios: (1) using empiric clopidogrel, (2) using empiric prasugrel, (3) using empiric ticagrelor, (4) switching from clopidogrel to prasugrel based on CYP2C19 genotype, and (5) switching from clopidogrel to ticagrelor based upon CYP2C19 genotype. 8 Based on a cohort of 100,000 patients with ACS who underwent percutaneous coronary intervention (PCI) and received at least 1 drug-eluting stent, the results suggested that CYP2C19 Financial Analysis of CYP2C19 Genotyping in Patients Receiving Dual Antiplatelet Therapy Following Acute Coronary Syndrome and Percutaneous Coronary Intervention probability of nonfatal stroke and nonfatal MI; however, they have an increased probability of CVD and nonfatal bleeding.…”

“…17 The predicted cost of CYP2C19 genotyping was set at $315 based on average cost. 8 Total cost for each therapy option was calculated by multiplying the number of patients, the number of adverse events, and cost of the adverse events. This was calculated separately for ultrarapid/extensive metabolizer patients and intermediate/ poor metabolizer patients.…”