OBJECTIVES: The decision of antiplatelet therapy after a percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) patients is complicated. Clopidogrel requires activation by cytochrome P450 (CYP), primarily CYP2C19. Patients with CYP2C19 loss-of-function alleles are at increased risk of major adverse cardiovascular events. Ticagrelor is a more effective and expensive alternative antiplatelet agent that is unaffected by the CYP2C19 polymorphism. Genotype-guided therapy is used to determine the CYP2C19 mutation carrier’s status so that the more expensive ticagrelor can be selectively prescribed to patients with loss-of-function alleles. The study aimed to evaluate the cost-effectiveness of CYP2C19*2/*3 genotype-guided antiplatelet therapy compared to the universal use of ticagrelor or clopidogrel in ACS patients who undergo PCI.

METHODS: A two-parts model, including a one-year decision-analytic model and a 20-years follow-up Markov model, was created from the Qatar health-care provider's perspective, to follow the use of (i) universal clopidogrel, (ii) universal ticagrelor, and (iii) genotype-guided antiplatelet therapy. Outcome measures were the incremental cost-utility ratio (ICUR) and incremental cost-effectiveness ratio (ICER) of genotype-guided therapy. Therapy success was defined as survival without myocardial infarction, stroke, stent thrombosis, cardiovascular death, or the no therapy discontinuation due to adverse events. The base-case modeling was based on a multivariate analysis of uncertainty in probabilistic and utility input data.

RESULTS: Base-case 1-year results illustrated that CYP2C19 genotype-guided therapy was cost-effective compared to the universal use of clopidogrel and ticagrelor (ICER of US$ 3,836 and 4,964, respectively, per one case of success without ADR). While the universal use of clopidogrel was dominant over the universal use of ticagrelor. Over the long-term Markov model, genotype-guided therapy was dominant compared to both universal ticagrelor and clopidogrel.

CONCLUSIONS: The CYP2C19 genotype-guided antiplatelet therapy appears to be the preferred antiplatelet strategy over the universal use of ticagrelor or clopidogrel for ACS patients undergoing PCI in Qatar.