A second look at data from a study comparing ticagrelor to clopidogrel in patients with acute coronary syndrome explored the comparative cost-effectiveness of the two treatments. Ticagrelor scored on value but editorial writers raised concerns.

In 2011, ticagrelor (Brilinta, AstraZeneca) was approved for use for prevention of thrombotic events in patients with acute coronary syndrome in the U.S. by the FDA with a boxed warning caveat that it be taken with low-dose aspirin only. This determination came from findings of the PLATO (Platelet Inhibition and Patient Outcomes) trial, comparing ticagrelor to generic clopidogrel. Higher doses of aspirin influenced a higher risk profile among patients in the U.S. group (1.27) as opposed to those in other countries (0.8 to 0.86) where combination therapy with low-dose aspirin was the norm.

Patricia A. Cowper, PhD, of Duke University Medical Center in Durham, N.C., and colleagues used PLATO data from the U.S. patients who paired ticagrelor with low-dose aspirin to understand the cost-effectiveness of this method of treatment.

Compared with patients given generic clopidogrel, patients given ticagrelor cost $1,495 less in observed cumulative one-year within-trial medical costs. However, the cost of ticagrelor for one year was $2,172 dollars more than the cost of a year of clopidogrel, meaning the total costs of using ticagrelor were higher than taking clopidogrel by approximately $1,400. Cowper et al estimated that at base case assumptions, ticagrelor was $29,665 per quality-adjusted life year gained compared with clopidogrel and below willingness-to-pay thresholds of $100,000.

Further, they noted that increasing the average cost of clopidogrel to $6 a day improved the incremental cost effectiveness ratio of ticagrelor to clopidogrel down to $17,288. The only scenario they found where ticagrelor was not cost-effective was one where reductions in mortality did not produce additional life expectancy beyond one year, they wrote. It “remained cost effective after recalibrating the underling mortality risk to reflect the U.S. PLATO clopidogrel cohort’s experience,” Cowper et al wrote.

While Cowper et al determined that ticagrelor was a cost-effective treatment, an editorial written by Dhruv S. Kazi, MD, MSC, MS, of the University of California, San Francisco, and Mark A. Hlatky, MD, of Stanford University School of Medicine, expressed concern about the risk of analyzing costs incrementally. “[P]olicy makers managing total budgets face tough decisions about whether they can bear the substantial additional expenditures for new, costly treatments: at an incremental cost of $2,172, using ticagrelor instead of generic clopidogrel for each of 650,000 ACS [acute coronary syndrome] episodes in the United States would lead to $1.4 billion in additional spending,” they wrote.

The study was published Feb. 10 in the Journal of the American College of Cardiology.