COST-EFFECTIVENESS OF ANTIPLATELET DRUGS AFTER PERCUTANEOUS CORONARY INTERVENTION

Purpose:

Hundreds of thousands of patients each year undergo percutaneous coronary intervention (PCI) after either a myocardial infarction (MI) or angina. Antiplatelet therapy with 12 months use of clopidogrel (Plavix) has long been considered standard treatment after a PCI in order to prevent MI and death. Recently two new drugs, prasugrel and ticagrelor, have been introduced, but there is uncertainty as to whether or not these new treatments offer value for money. Our objective was to compare the cost-effectiveness of different antiplatelet drugs for patients who have undergone PCI.

Method:

We modified a previously developed probabilistic Markov model to fit the current research question. The model applies a lifelong health care payer perspective after a PCI operation including risk of MI, major bleeding, new revascularization (PCI or coronary artery bypass graft) and death. All costs and health benefits were discounted at 4% as recommended in national guidelines.

Efficacy data of prasugrel and ticagrelor compared to clopidogrel were based on the two licensing phase III randomized controlled trials including 13 608 and 18 624 participants, respectively. Outcomes included significant reductions in risk of MI for both drugs, increased risk of bleeding and reduced risk of revascularization with prasugrel and reduced overall mortality with ticagrelor.

Costs of all three antiplatelet drugs are based on current prices from the Norwegian Medicines Agency; EUR 207 per year for Clopidogrel, EUR 509 per year for Prasugrel and EUR 817 per year for Ticagrelor.

Result:

60-year old patients undergoing PCI had a life expectancy of 17.52 (11.96 discounted) if treated with clopidogrel the first year. Treatment with prasugrel increased life expectancy to 18.21 (12.30 discounted), while ticagrelor resulted in 19.04 life years (12.69 discounted). Ticagrelor was cost-effective compared to clopidogrel at an ICER of EUR 8 000 per life year gained, while prasugrel was extendedly dominated by ticagrelor and clopidogrel. At an assumed cost-effectiveness threshold of EUR 70 000 per life year gained, 77%, 23% and 0.1% of simulations indicated that ticagrelor, prasugrel and clopidogrel were cost-effective, respectively.

Conclusion:

Ticagrelor is clearly cost-effective compared to prasugrel and clopidogrel for a Norwegian setting.