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

Wout W A van den Broek; Jacqueline G van Paassen; Marieke E Gimbel; Vera H M Deneer; Jurriën M Ten Berg; Rick A Vreman

doi:10.1093/ehjcvp/pvac037

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

Eur Heart J Cardiovasc Pharmacother. 2022 Dec 15;9(1):76-84. doi: 10.1093/ehjcvp/pvac037.

Authors

Wout W A van den Broek¹, Jacqueline G van Paassen², Marieke E Gimbel³, Vera H M Deneer^{2

4}, Jurriën M Ten Berg^{1

5}, Rick A Vreman²

Affiliations

¹ Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
² Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Heidelberglaan 8, 3584 CS, Utrecht, The Netherlands.
³ Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands.
⁴ Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Centre Utrecht, Heidelberglaan 8, 3584 CS, Utrecht, The Netherlands.
⁵ Cardiovascular Research Institute Maastricht (CARIM), Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands.

Abstract

Objective: The POPular AGE trial showed that clopidogrel significantly reduced bleeding risk compared with ticagrelor without any signs of an increase in thrombotic events. The aim of this analysis was to estimate the long-term cost-effectiveness of clopidogrel compared with ticagrelor in these patients aged 70 years or older with non-ST-elevation acute coronary syndrome (NSTE-ACS).

Methods and results: 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 NSTE-ACS. 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 costs and effects for a fictional cohort of 1000 patients. Treatment with clopidogrel instead of ticagrelor led to a cost saving of €1484 575 (€1485 per patient) and a decrease of 10.96 QALYs (0.011 QALY per patient) in the fictional cohort. In an alternative base case with equal distribution over health states in the first year, treatment with clopidogrel led to an increase in QALYs. In all scenario analyses, treatment with clopidogrel was cost-saving.

Conclusion: Clopidogrel is a cost-saving alternative to ticagrelor in elderly patients after NSTE-ACS, though regarding overall cost-effectiveness clopidogrel was not superior to ticagrelor, as it resulted in a small negative effect on QALYs. However, based on the results of the alternative base case and clinical outcomes of the POPular AGE trial, clopidogrel could be a reasonable alternative to ticagrelor for elderly NSTE-ACS patients with a higher bleeding risk.

Trial registration: ClinicalTrials.gov NCT02317198.

Keywords: Coronary artery disease; Cost-effectiveness; Elderly; NSTE-ACS; P2Y12-inhibitor.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Acute Coronary Syndrome* / diagnosis
Acute Coronary Syndrome* / drug therapy
Aged
Clopidogrel / adverse effects
Cost-Benefit Analysis
Humans
Platelet Aggregation Inhibitors / adverse effects
Ticagrelor / adverse effects
Ticlopidine / adverse effects

Substances

Ticagrelor
Clopidogrel
Ticlopidine
Platelet Aggregation Inhibitors

Associated data

ClinicalTrials.gov/NCT02317198
NTR/NTR3991