Cost-effectiveness of clopidogrel versus ticagrelor in patients of 70 years or older with non-ST-elevation acute coronary syndrome

Abstract

Abstract Background/Introduction In older patients with non-ST-elevation acute coronary syndrome (NSTEMI) the POPular AGE trial clopidogrel showed superiority to ticagrelor in reducing bleeding risk and non-inferiority in net clinical benefit (all-cause death, myocardial infarction, stroke, and PLATelet inhibition and patient Outcomes; major or minor bleeding). Purpose The aim of this analysis was to estimate the long-term cost-effectiveness of clopidogrel compared to ticagrelor in these older patients with NSTEMI and to address the impact on quality of life by both treatment strategies. Methods A 1-year decision tree based on the POPular AGE trial in combination with a lifelong Markov model was developed to compare clopidogrel with ticagrelor in terms of clinical outcomes, costs and quality-adjusted life years (QALYs) in elderly patients (above 70 year) with NSTEMI. Cost-effectiveness was assessed from a Dutch healthcare system perspective. Events rates and utility data observed in the POPular AGE trial were combined with lifetime projections to evaluate cost and effects for a fictional cohort of 1000 patients. Deterministic, probabilistic sensitivity analyses and several scenario analyses were performed. The several scenario's included different time horizons, identical prices for P2Y12-inhibitors, different health utilities in the clopidogrel and ticagrelor arm and a prolonged duration of bleeding disutility. Results Treatment with clopidogrel instead of ticagrelor led to a cost saving of €1,482,775 (€1,483 per patient) and a decrease of 10,96 quality-adjusted life years (QALY's) (0.011 QALY per patient) in the fictional cohort. In an alternative base case with equal distribution over health states in the first year based on the non-inferiority of the POPular AGE trial, treatment with clopidogrel was the dominant strategy both cost saving and increasing QALY's. In all scenario analyses, treatment with clopidogrel was cost saving. In the scenario with different health utilities in the clopidogrel and ticagrelor arm, the distinct average reported health utilities in both treatment arms were used. In this scenario clopidogrel was the dominant strategy. Conclusion This analysis shows that clopidogrel is a cost-saving alternative to ticagrelor in elderly patients after NSTEMI, with a very small negative effect on QALY's. It supports the conclusion of the POPular AGE trial to regard clopidogrel as a favourable alternative to ticagrelor in the elderly patient after a NSTEMI. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ZonMw