OBJECTIVES: To evaluate the cost-effectiveness of prasugrel versus clopidogrel, in combination with aspirin, in patients undergoing planned percutaneous coronary intervention (PCI) from the healthcare provider’s perspective in the United States.
METHODS: Second-order Monte Carlo simulation was conducted using TreeAge Pro (2009) following the ISPOR task force guidelines for modeling. Model branches included PCI type (bare metal stent and drug eluting stent), CYP2C19 polymor- phisms, and clinical outcomes. Model inputs such as costs (2009 dollar value), age-adjusted quality of life, and probabilities were identified through systematic literature review. All future costs and QALYs were discounted by 5%. Life expec- tancy was estimated using declining exponential approximation of life expectancy (DEALE) method. Acceptability curve was plotted to determine the most cost-effec- tive strategy at various willingness-to-pay (WTP) thresholds ($0-$250,000/QALY). One-way sensitivity analyses were performed to determine if the model was sen- sitive to variation in probabilities, costs and disutilities associated with myocardial infarction (MI), stroke and major bleeding.
RESULTS: Clopidogrel therapy resulted in lifetime costs and utilities of $17,208 and 10.4124 QALYs compared with $16,780 and 10.4057 QALYs for prasugrel therapy. The ICER for clopidogrel was $63,840/ QALYs. The acceptability curve showed that prasugrel was not likely cost-effective with 80% certainty at any WTP threshold. One-way sensitivity analyses (WTP decision threshold: $100,000/QALY) showed that prasugrel is the most cost-effec- tive strategy when probability of MI is increased by 12%, probability of bleeding is decreased by 24%, and disutility associated with MI is 0.1634. When only pa- tients with variant CYP2C19 were considered, the ICER was found to be $2,313,333/ QALY for clopidogrel.
CONCLUSIONS: Inconclusive results indicate that there is no benefit in prescribing one therapy over the other for the entire patient population. CYP2C19 polymorphism should be given consideration during the decision making process. For the base-case scenario, prasugrel therapy was the preferred strategy in patients with variant CYP2C19.
