TCT: Prasugrel costs hospitals less than clopidogrel, due to less repeat PCI
SAN FRANCISCO--For patients with acute coronary syndromes (ACS) undergoing PCI, treatment with prasugrel compared with clopidogrel was associated with significant cost offsets—mainly derived from reductions in repeat PCI—in both the first 30 days as well as longer term treatment (median 14.7 months), based on an economic substudy of the TRITON-TIMI 38 trial presented Thursday during the late breaking clinical trials at the 2009 Transcatheter Cardiovascular Therapeutics (TCT) annual meeting.

Given the higher acquisition cost of prasugrel (Effient; Eli Lilly and Daiichi Sankyo) and the substantial population who may be candidates for treatment, economic factors may be an important consideration in identifying the optimal patient population and treatment duration, according to study presenter and lead author David J. Cohen, MD, from Saint-Luke’s Mid America Heart Institute in Kansas City, Mo.

He and his colleagues sought to compare total medical care costs for ACS patients undergoing PCI and treated with prasugrel versus clopidogrel (Plavix; Bristol-Myers Squibb) over the duration of the TRITON trial.

They examined all patients (6,705) from eight countries, which were selected for similar resource patterns to U.S. practice and the feasibility of collecting detailed resource utilization.

The researchers calculated the costs for hospitalizations and physician services by multiplying resource counts by U.S.-specific unit costs (in 2005 dollars) derived from Medicare data. The study drug costs were based on net wholesale price as of August 2009 (clopidogrel, $4.62/day or $141/month and Prasugrel, $5.45/day or $166/month).

They found that the number of rehospitalizations per 1,000 patients was 36.3 percent less for repeat PCI for prasugrel compared with clopidogrel, and there was an 11 percent increase in bleeding events with prasugrel compared with clopidogrel.

Also, Cohen reported that the index hospitalization cost with prasugrel was $19,740, and $19,752 with clopidogrel, equaling a $12 reduction for prasugrel. Rehospitalization cost for prasugrel was $4,465, and $4,982 for clopidogrel—a $517 reduction for prasugrel. Finally, the drug costs were $308 more for prasugrel over the course of the study period.

For total costs, prasugrel was associated with a $221 reduction for hospitals.

Also, compared with generic clopidogrel (expected cost $1/day), “prasugrel was cost saving during the first 30 days but resulted in higher costs beyond this time period,” Cohen said. Nonetheless, he said the cost effectiveness of prasugrel versus generic clopidogrel was favorable (less than $20,000/life years gained) for both the subacute- and longer-term phases of treatment.

As indicated, these cost offsets were derived predominantly from reductions in repeat PCI—both with and without subsequent MI—and occurred despite a modest increase in costs related to bleeding events.

“Although the acquisition cost of prasugrel was about $300 greater than clopidogrel,” according to Cohen, “total medical care costs remained lower for prasugrel both during the first 30 days as well as the subsequent 13 months.”

Also, he reported that their results were consistent across most subgroups with the exception of patients with previous stroke/transient ischemic attack and patients at high risk of bleeding (age higher than 75, weight of less than 60 kg).

However, Cohen acknowledged that further studies will be necessary to understand the optimal duration of treatment and the cost effectiveness of prasugrel in other, non-ACS settings.