Cost Effectiveness of Genotype-Guided Antiplatelet Therapy in Asian Ischemic Stroke Patients: Ticagrelor as an Alternati
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ORIGINAL RESEARCH ARTICLE
Cost Effectiveness of Genotype‑Guided Antiplatelet Therapy in Asian Ischemic Stroke Patients: Ticagrelor as an Alternative to Clopidogrel in Patients with CYP2C19 Loss of Function Mutations Kaavya Narasimhalu1 · Yoong Kwei Ang2,4 · Doreen Su Yin Tan2,3 · Deidre Anne De Silva1 · Kelvin Bryan Tan2,5
© Springer Nature Switzerland AG 2020
Abstract Background Patients with ischemic stroke are often treated with clopidogrel monotherapy as part of secondary stroke prevention. The prevalence of loss of function (LOF) mutations in the CYP2C19 gene is higher in Asians than in Western populations. Patients with loss of function (LOF) mutations are at risk for poorer secondary outcomes when prescribed clopidogrel. Objective We aimed to determine the cost effectiveness of genotype-guided antiplatelet therapy in an Asian population with the aim of prescribing ticagrelor as an alternative to patients with LOF mutations. Methods Markov models were developed to look at the cost effectiveness of genetic testing of CYP2C19, with patients who screened positive for LOF alleles being switched to ticagrelor compared to universal clopidogrel treatment. Effect ratios were obtained from the literature and incidence rates and costs were obtained from the national data published by the Singapore Ministry of Health. Lifetime costs and quality-adjusted life-years (QALYs) were calculated. The primary endpoints were the incremental cost-effectiveness ratios (ICERs). Results The prevalence of the LOF mutations was 61% in the population, with 65% of ethnic Chinese, 60% of ethnic Indian, and 53% of ethnic Malay patients having LOF mutations. Based on this prevalence, the overall ICER of genetic testing was S$33,839/QALY with ICERS of S$30,755/QALY, S$33,177/QALY, and S$41,470/QALY for Chinese, Indians, and Malays, respectively. Conclusion This study suggests that it is cost effective to screen for LOF mutations in the CYP2C19 gene in ischemic stroke populations, with ticagrelor as a substitute for clopidogrel in those with LOF mutations.
1 Introduction Patients with ischemic stroke receive antiplatelet therapy as one of the main treatments for secondary prevention. Clopidogrel and aspirin are the two antiplatelet medications that * Kaavya Narasimhalu [email protected] 1
Department of Neurology (SGH Campus), National Neuroscience Institute, Outram Road, 169608 Singapore, Singapore
2
Policy, Research and Evaluation Division, Ministry of Health, Singapore, Singapore
3
Khoo Teck Puat Hospital, Singapore, Singapore
4
Sydney Medical School, University of Sydney, Sydney, NSW, Australia
5
School of Public Health, National University of Singapore, Singapore, Singapore
Key Points It is cost effective to screen for resistance to clopidogrel in Asian ischemic stroke patients. Genotype-guided antiplatelet therapy with ticagrelor as an alternative to clopidogrel in patients with LOF mutations is cost effective in secondary stroke prevention.
are commonly used for secondary prevention in patients wit
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