Efficacy, cost-effectiveness data favor new antiplatelets over clopidogrel in patients with ACS

TCT 2009

The results of PLATO INVASIVE and TRITON-TIMI 38 indicated that two new antiplatelet agents, ticagrelor and prasugrel, may have unique advantages over the standard clopidogrel.

In the first study, PLATO INVASIVE, researchers compared outcomes between ticagrelor (Brilinta, AstraZeneca) and clopidogrel therapy in 13,408 patients with acute coronary syndromes. The study researchers, led by Christopher P. Cannon, MD, of Brigham and Women’s Hospital, randomly assigned patients to ticagrelor (n=6,732) or clopidogrel (n=6,676) for six to 12 months. The primary endpoint was the composite of CV death, MI or stroke.

Patients assigned ticagrelor had a 16% reduction in the primary endpoint at one year (95% CI, 0.75-0.84).

Investigators also said that patients assigned ticagrelor had a 19% reduction in all-cause mortality in addition to reduction in CV death and MI.

No differences were reported in major bleeding, life-threatening bleeding or fatal bleeding. Dyspnea was higher with ticagrelor vs. clopidogrel (15.4% vs. 10.4%, P<.0001).

“This analysis supports the notion that ticagrelor is a reversible but more intense P2Y12 antagonist that is more effective than clopidogrel when given for one year following ACS in patients managed invasively,” Cannon said during his presentation. “It is also more effective for the continuous prevention of ischemic events, stent thrombosis and death without an increase in major bleeding.”

TRITON-TIMI

The economic substudy of the TRITON-TIMI 38 study was presented by David J. Cohen, MD, of St. Luke’s Mid America Heart Institute in Kansas City, Mo. This study compared the total medical care costs of 6,705 patients receiving PPIs for ACSs treated with prasugrel (Effient; Daiichi Sankyo, Eli Lilly) vs. clopidogrel. Patients assigned to prasugrel had less of the combined TRITON endpoint of CV death, MI and stroke for the economic substudy (12.1% vs. 9.9%, P<.006) and for the overall trial population (12.1% vs. 9.9%, P<.0001) when compared with patients assigned clopidogrel.

Index hospitalization costs between the two drugs were similar ($19,752 with clopidogrel vs. $19,740 with prasugrel). However, rehospitalization costs were slightly higher for patients assigned to clopidogrel ($4,982 vs. $4,465). While the acquisition cost of prasugrel was $308 higher than that of clopidogrel.

Overall, the cost savings of prasugrel was $221 per 0.102 years of life expectancy gained. The savings were greater during the first 30 days of the trial (cost savings of $192 for 0.056 years of life expectancy gained) compared with day 31 to the end of the trial (cost savings of $28 for 0.053 years of life expectancy gained), Cohen said.

“Compared with generic clopidogrel at an expected cost of $1 per day, prasugrel was cost saving during the first 30 days but resulted in higher costs beyond this time period,” Cohen concluded. “Nevertheless, our analysis suggested that the cost-effectiveness of prasugrel vs. generic clopidogrel would be reasonably favorable for both the subacute and longer-term phases of treatment.

“The results were consistent across most subgroups with the exception of patients with previous stroke or transient ischemic attack and patients at very high risk for bleeding,” Cohen said.

For more information:

Cannon CP. Plenary session XII. LBCT II.
Cohen DJ. Plenary session XII. LBCT II.
Both presented at: Transcatheter Cardiovascular Therapeutics 2009; Sept. 21-25; San Francisco.