CYP2C19 Genotype-Guided Antiplatelet Therapy Among Asian Patients with Ischaemic Stroke
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LETTER TO THE EDITOR
CYP2C19 Genotype‑Guided Antiplatelet Therapy Among Asian Patients with Ischaemic Stroke Chia Siang Kow1 · Abdullah Faiz Zaihan2 · Syed Shahzad Hasan3,4 Accepted: 29 October 2020 © Springer Nature Switzerland AG 2020
We read with interest the cost-effectiveness study by Narasimhalu et al. [1], which evaluated the cost effectiveness of CYP2C19 genotype-guided antiplatelet therapy in an Asian population of patients presenting with acute ischaemic stroke with the aim of prescribing ticagrelor instead of clopidogrel to patients with CYP2C19 loss-of-function mutations. The base-case analysis reported that CYP2C19 genotype-guided antiplatelet therapy resulted in an incremental cost-effectiveness ratio of Singapore Dollar (SGD) 33,839 per quality-adjusted life-year (QALY), which is far lower than the cost-effectiveness threshold of one GDP per capita (SGD 87,000/QALY) as recommended by the World Health Organization. In fact, the sensitivity analyses had proven the robustness of the findings. The Food and Drug Administration (FDA) of the USA issued a black box warning in 2010 on clopidogrel prescribing label to warn that clopidogrel has reduced effect on platelet activities in patients with CYP2C19 loss-of-function mutation [2]. In addition, FDA advised that the use of other antiplatelet agents should be considered in those who are identified as poor metabolisers based on CYP2C19 genotype testing [2]. Furthermore, the Clinical Pharmacogenetics Implementation Consortium [3] recommended CYP2C19 genotype-guided antiplatelet therapy with a switch to an alternative antiplatelet agent such as ticagrelor, which is not This letter refers to the article available at https://doi.org/10.1007/ s40261-020-00970-y. * Chia Siang Kow [email protected] 1
School of Postgraduate Studies, International Medical University, Kuala Lumpur, Malaysia
2
Department of Pharmacy, Shah Alam Hospital, Selangor, Malaysia
3
Department of Pharmacy, University of Huddersfield, Huddersfield, United Kingdom
4
School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, Australia
affected by CYP2C19 polymorphism in patients identified as intermediate or poor metabolisers. However, the recommendation is mainly for acute coronary syndrome patients undergoing percutaneous coronary intervention, as at that point of time, there was no conclusive clinical evidence to support the use of ticagrelor in patients with acute ischaemic stroke or transient ischaemic attack. Despite that discussion of CYP2C19 genotype-guided antiplatelet therapy has been ongoing for years, it is surprising to note that there was no official recommendation on the utilisation of genotype-guided antiplatelet therapy among patients with ischaemic stroke from clinical practice guidelines, medical consensus, or position papers in Asian countries where the prevalence of CYP2C19 loss-of-function mutation is higher compared to European countries. For instance, despite two previous studies [4, 5] showing a prevalence of CYP2C19 loss-
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