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Cost-effectiveness of testing for CYP2C19 loss-of-function carriers following transient ischemic attack/minor stroke:
Andrew Micieli1, Nishita Singh1, Beate Jahn2
1Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
Insights
Testing for CYP2C19 loss-of-function (LOF) alleles to guide antiplatelet therapy after TIA/minor stroke is cost-effective. This personalized approach improves life-years and quality-adjusted life-years, offering significant value in the Canadian healthcare system.
Area of Science:
- Pharmacogenomics
- Cardiovascular Medicine
- Health Economics
Background:
- The CHANCE-2 study indicated aspirin-ticagrelor may reduce stroke recurrence compared to aspirin-clopidogrel in CYP2C19 loss-of-function (LOF) allele carriers post-TIA/minor stroke.
- This benefit was associated with increased bleeding risk, and the cost-effectiveness of genetic testing for personalized antiplatelet therapy in Canada was unknown.
Purpose of the Study:
- To evaluate the cost-effectiveness of implementing CYP2C19 LOF allele testing for personalized antiplatelet therapy selection in Canadian patients post-TIA/minor stroke.
- To compare the costs and health benefits of LOF allele testing against the current standard of care.
Main Methods:
- A decision-analytic Markov cohort model with a lifetime horizon was utilized for cost-effectiveness analysis.
- The model incorporated data from the Canadian healthcare perspective, including costs, life-years gained (LYG), and quality-adjusted life years (QALYs).
- Sensitivity analyses were conducted to assess the robustness of the findings.
Main Results:
- LOF allele testing resulted in an additional 0.14 LYG and 0.12 QALYs gained per patient, with a modest lifetime cost increase of CAD$432.
- The incremental cost-effectiveness ratio (ICER) was CAD$4310 per QALY gained.
- Probabilistic sensitivity analyses showed LOF allele testing to be cost-effective in over 99.99% of simulations at a willingness-to-pay threshold of CAD$50,000 per QALY.
Conclusions:
- Testing for CYP2C19 LOF alleles to guide short-term aspirin-ticagrelor therapy post-TIA/minor stroke is a cost-effective strategy.
- This personalized approach offers prolonged life and improved quality of life, demonstrating strong value compared to existing healthcare interventions.
Background:
The CHANCE-2 study compared 3 weeks of aspirin-ticagrelor to aspirin-clopidogrel in CYP2C19 loss-of-function (LOF) allele carriers following a transient ischemic attack (TIA)/minor stroke and demonstrated a modestly lower risk of stroke recurrence with aspirin-ticagrelor. This stroke protection was largely for minor stroke and came at an increased risk of bleeding. The cost-effectiveness of implementing testing for LOF allele status to personalize antiplatelet regimen for secondary stroke prevention after a TIA/minor stroke in the Canadian health care context is unknown.
Methods:
Cost-effectiveness analysis using a decision-analytic Markov cohort model with a lifetime horizon was performed to determine the costs and health benefits of testing for LOF allele status compared with no testing (current standard of care). The population of interest was patients living in Canada who suffered a TIA/minor stroke. Outcomes of interest were life-years gained (LYG), quality-adjusted life years (QALY) gained, costs (reported in 2022 Canadian dollars), and the incremental cost-effectiveness ratio (ICER). We adopted the perspective of the Federal, Provincial, and Territorial Ministries of Health and used a 1.5% annual discount rate. Sensitivity analyses were performed to assess uncertainty.
Results:
Compared to standard of care, LOF allele testing leads to 0.14 LYG (undiscounted), 0.12 QALYs gained (undiscounted), and additional lifetime costs of CAD$432 (discounted) per patient. The ICER of the LOF allele testing strategy is CAD$4310 per QALY gained compared with standard of care. The probabilistic sensitivity analyses demonstrated that LOF allele testing was cost-effective in more than 99.99% of simulations using a willingness-to-pay threshold of CAD$50,000 per QALY.
Conclusion:
Based on available evidence, testing for LOF allele followed by short duration 3 weeks of aspirin-ticagrelor compared to standard-of-care aspirin-clopidogrel can lead to prolonged life and improved quality of life and can be considered very cost-effective when compared with other well-accepted technologies in health and medicine.
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