Twenty lives and $440,000 over a year. For every 1,000 patients.
That’s what CYP2C19 pharmacogenetic testing could save if used to help prescribe clopidogrel (Plavix), prasugrel or ticagrelor to specific cardiac patients.
A budget analysis found that a genotype-guided approach for acute coronary syndrome patients (ACS) undergoing percutaneous coronary intervention (PCI) for one year saved 20 lives and $444,852 in healthcare costs within a 1,000-patient cohort. This analysis assumed 100 percent of patients were genotyped for variants in the CYP2C19 drug-metabolizing enzyme, which processes clopidogrel.
“Important financial benefits may be realized through use of genotype-guided antiplatelet therapy to reserve prasugrel or ticagrelor use for patients with reduced CYP2C19 activity to avoid costs associated with adverse cardiac events,” authors Johnson et al. write.
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Financial Impact of Testing
The budget analysis sought to estimate the financial impact of CYP2C19 testing in a theoretical cohort of ACS/PCI patients being treated with clopidogrel, prasugrel (Effient) or ticagrelor (Brilinta). Prasugrel and ticagrelor do not require activation by the CYP2C19 enzyme, but both are more expensive than clopidogrel. Furthermore, compared with clopidogrel, prasugrel has an increased risk of bleeding. Ticagrelor, on the other hand, has a possible increased risk of dyspnea and is dosed twice daily instead of once daily, which could cause a patient to be less adherent to the medication.
Authors Johnson et al. compared three groups of theoretical patients: One where none of the patients were tested or genotyped for CYP2C19, another where half the patients were tested and the third where all patients were tested. They estimated healthcare spending based on costs of treating adverse cardiac events, price of genotyping and prescription drug costs.
Across both the 50 percent and 100 percent testing scenarios, the genotype-guided approach showed reductions in costs per patients, cardiovascular death and nonfatal myocardial infarction.
Specifically, the 100-percent-testing scenario showed a 27 percent decrease in cardiovascular deaths (75 to 55), compared to no testing, and a 5 percent decrease in per-patient costs ($8,866 to $8,421). Instance of nonfatal myocardial infarction (heart attacks) decreased 14 percent (229 to 197) between the no-testing and 100-percent-testing scenarios.
Why CYP2C19 Testing Matters
The study adds support to the clinical utility of CYP2C19 testing for clopidogrel patients. The results also gel with a recent decision by Noridian Healthcare Solutions, a Medicare Administrative Contractor, confirming coverage for CYP2C19 testing in ACS/PCI patients starting or restarting clopidogrel.
In 2010, the FDA placed a boxed warning on clopidogrel explaining that patients with CYP2C19 genetic variations were at an increased risk of heart attack and stroke. However, testing for genetic variants that could have an impact on clopidogrel response is still not the standard of care.
The paper explaining these findings was published this month in the Journal of Managed Care & Specialty Pharmacy. Researchers from Kaiser Permanente Colorado, a leading nonprofit healthcare provider, and a former Genelex pharmacist produced the study.