Cost-effectiveness of platelet function testing in dual antiplatelet therapy decision-making after intracranial aneurysm treatment with flow diversion.
Aneurysm
Antiplatelet
Cost-effectiveness
Flow diversion
Journal
Neurosurgical review
ISSN: 1437-2320
Titre abrégé: Neurosurg Rev
Pays: Germany
ID NLM: 7908181
Informations de publication
Date de publication:
27 Aug 2024
27 Aug 2024
Historique:
received:
03
07
2024
accepted:
08
08
2024
revised:
04
08
2024
medline:
27
8
2024
pubmed:
27
8
2024
entrez:
27
8
2024
Statut:
epublish
Résumé
Dual antiplatelet therapy (DAPT) use is the standard of practice after flow diversion (FD) for intracranial aneurysms (IAs). Yet, no consensus exists in the literature regarding the optimal regimen. Certain institutions utilize various platelet function testing (PFT) to assess patient responsiveness to DAPT. Clopidogrel is the most commonly prescribed drug during DAPT; however, up to 52% of patients can be non-responders, justifying PFT use. Additionally, prices vary significantly among antiplatelet drugs, often further complicated by insurance restrictions. We aimed to determine the most cost-effective strategy for deciding DAPT regimens for patients after IA treatment. A decision tree with Monte Carlo simulations was performed to simulate patients undergoing various three-month postoperative DAPT regimens. Patients were either universally administered aspirin alongside clopidogrel, ticagrelor, or prasugrel without PFT, or administered one of the former thienopyridine medications based on platelet reactivity unit (PRU) results after clopidogrel. Input data for the model were extracted from the current literature, and the willingness-to-pay threshold (WTP) was defined as $100,000 per QALY as per standard practice in the US. The baseline comparison was with universal clopidogrel DAPT without any PFT. Probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of the model. Utilizing PFT and switching clopidogrel to prasugrel if resistance is documented was the most cost-effective regimen compared to universal clopidogrel, with a base-case incremental cost-effectiveness ratio (ICER) of $-35,255 (cost $2,336.67, effectiveness 0.85). Performing PFT and switching clopidogrel to ticagrelor (ICER $-4,671; cost $2,995.06, effectiveness 0.84), universal prasugrel (ICER $5,553; cost $3,097.30, effectiveness 0.84), or universal ticagrelor (ICER $75,969; cost $3,801.36, effectiveness 0.84) were all more cost-effective than treating patients with universal clopidogrel (cost $3,041.77, effectiveness 0.83). These conclusions remain robust in probabilistic and deterministic sensitivity analyses. The most cost-effective strategy guiding DAPT after FD for IAs is to perform PFTs and switch clopidogrel to prasugrel if resistance is documented, alongside aspirin. The cost of PFT is strongly justified and recommended when deciding patient-specific DAPT regimens.
Identifiants
pubmed: 39190045
doi: 10.1007/s10143-024-02668-7
pii: 10.1007/s10143-024-02668-7
doi:
Substances chimiques
Platelet Aggregation Inhibitors
0
Clopidogrel
A74586SNO7
Prasugrel Hydrochloride
G89JQ59I13
Aspirin
R16CO5Y76E
Ticagrelor
GLH0314RVC
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
483Informations de copyright
© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.
Références
Mirpuri P, Khalid SI, McGuire LS, Alaraj A (2023) Trends in Ruptured and Unruptured Aneurysmal Treatment from 2010 to 2020: a focus on Flow Diversion. World Neurosurg 178:e48–e56. https://doi.org/10.1016/j.wneu.2023.06.093
doi: 10.1016/j.wneu.2023.06.093
pubmed: 37385440
Gupta R, Moore JM, Griessenauer CJ et al (2016) Assessment of Dual-Antiplatelet Regimen for Pipeline Embolization device Placement: a Survey of Major Academic Neurovascular centers in the United States. World Neurosurg 96:285–292. https://doi.org/10.1016/j.wneu.2016.09.013
doi: 10.1016/j.wneu.2016.09.013
pubmed: 27641263
Taylor LI, Dickerson JC, Dambrino RJ et al (2017) Platelet testing in flow diversion: a review of the evidence. Neurosurg Focus 42(6):E5. https://doi.org/10.3171/2017.3.FOCUS1746
doi: 10.3171/2017.3.FOCUS1746
pubmed: 28565991
Lim ST, Thijs V, Murphy SJX et al (2020) Platelet function/reactivity testing and prediction of risk of recurrent vascular events and outcomes after TIA or ischaemic stroke: systematic review and meta-analysis. J Neurol 267(10):3021–3037. https://doi.org/10.1007/s00415-020-09932-y
doi: 10.1007/s00415-020-09932-y
pubmed: 32518978
Adeeb N, Griessenauer CJ, Foreman PM et al (2017) Use of platelet function testing before Pipeline Embolization device Placement: a Multicenter Cohort Study. Stroke 48(5):1322–1330. https://doi.org/10.1161/STROKEAHA.116.015308
doi: 10.1161/STROKEAHA.116.015308
pubmed: 28411263
Coleman CI, Limone BL (2013) Cost-effectiveness of Universal and platelet reactivity assay-driven antiplatelet therapy in Acute Coronary Syndrome. Am J Cardiol 112(3):355–362. https://doi.org/10.1016/j.amjcard.2013.03.036
doi: 10.1016/j.amjcard.2013.03.036
pubmed: 23631863
Mehta SR, Tanguay JF, Eikelboom JW et al (2010) Double-dose versus standard-dose clopidogrel and high-dose versus low-dose aspirin in individuals undergoing percutaneous coronary intervention for acute coronary syndromes (CURRENT-OASIS 7): a randomised factorial trial. Lancet 376(9748):1233–1243. https://doi.org/10.1016/S0140-6736(10)61088-4
doi: 10.1016/S0140-6736(10)61088-4
pubmed: 20817281
Suyama K, Nakahara I, Matsumoto S et al (2024) Efficacy and safety of dual antiplatelet therapy with the routine use of Prasugrel for Flow Diversion of Cerebral Unruptured aneurysms. Clin Neuroradiol 34(1):201–208. https://doi.org/10.1007/s00062-023-01355-2
doi: 10.1007/s00062-023-01355-2
pubmed: 37847296
Papaxanthos J, Cagnazzo F, Collemiche FL et al (2023) Ticagrelor versus Clopidogrel dual antiplatelet therapy for unruptured intracranial aneurysms treated with flowdiverter. J Neuroradiol 50(3):346–351. https://doi.org/10.1016/j.neurad.2022.11.010
doi: 10.1016/j.neurad.2022.11.010
pubmed: 36642161
Flynn LM, Mohamed E, Dobbs N et al (2023) Safety of dual antiplatelet therapy using aspirin and low-dose prasugrel with platelet reactivity testing in flow diverter treatment of intracranial aneurysms. Interv Neuroradiol. Published Online November 29:15910199231217142. https://doi.org/10.1177/15910199231217142
doi: 10.1177/15910199231217142
Neyens R, Donaldson C, Andrews C, Kellogg R, Spiotta A (2020) Platelet function testing with a VerifyNow-Directed Personalized Antiplatelet Strategy and Associated Rates of Thromboembolic complications after Pipeline Embolization for Complex Cerebral aneurysms. World Neurosurg 138:e674–e682. https://doi.org/10.1016/j.wneu.2020.03.046
doi: 10.1016/j.wneu.2020.03.046
pubmed: 32194270
Podlasek A, Al Sultan AA, Assis Z, Kashani N, Goyal M, Almekhlafi MA (2020) Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis. J Neurointerv Surg 12(2):148–155. https://doi.org/10.1136/neurintsurg-2019-014996
doi: 10.1136/neurintsurg-2019-014996
pubmed: 31273075
Salem MM, Salih M, Nwajei F et al (2022) Cost-effectiveness Analytic Comparison of Neuroimaging Follow-Up strategies after Pipeline Embolization device treatment of Unruptured Intracranial aneurysms. World Neurosurg 158:e206–e213. https://doi.org/10.1016/j.wneu.2021.10.154
doi: 10.1016/j.wneu.2021.10.154
pubmed: 34757210
Wali AR, Park CC, Santiago-Dieppa DR, Vaida F, Murphy JD, Khalessi AA (2017) Pipeline embolization device versus coiling for the treatment of large and giant unruptured intracranial aneurysms: a cost-effectiveness analysis. Neurosurg Focus 42(6):E6. https://doi.org/10.3171/2017.3.FOCUS1749
doi: 10.3171/2017.3.FOCUS1749
pubmed: 28565986
pmcid: 6369699
Brinjikji W, Lanzino G, Cloft HJ, Siddiqui AH, Kallmes DF (2015) Risk factors for hemorrhagic complications following Pipeline Embolization device treatment of Intracranial aneurysms: results from the International Retrospective Study of the Pipeline Embolization device. AJNR Am J Neuroradiol 36(12):2308–2313. https://doi.org/10.3174/ajnr.A4443
doi: 10.3174/ajnr.A4443
pubmed: 26251427
pmcid: 7964264
Brinjikji W, Lanzino G, Cloft HJ et al (2016) Risk factors for ischemic complications following Pipeline Embolization device treatment of Intracranial aneurysms: results from the IntrePED Study. AJNR Am J Neuroradiol 37(9):1673–1678. https://doi.org/10.3174/ajnr.A4807
doi: 10.3174/ajnr.A4807
pubmed: 27102308
pmcid: 7984677
Zhou Y, He S, Hu Y (2024) One year clinical outcome of dual anti-platelet therapy with the Novel Ticagrelor plus Aspirin versus Clopidogrel plus Aspirin for Endovascular intervention of patients with intracranial aneurysm: a meta-analysis. J Stroke Cerebrovasc Dis 33(1):107491. https://doi.org/10.1016/j.jstrokecerebrovasdis.2023.107491
doi: 10.1016/j.jstrokecerebrovasdis.2023.107491
pubmed: 37988833
Limdi NA, Cavallari LH, Lee CR et al (2020) Cost-effectiveness of CYP2C19-guided antiplatelet therapy in patients with acute coronary syndrome and percutaneous coronary intervention informed by real-world data. Pharmacogenomics J 20(5):724–735. https://doi.org/10.1038/s41397-020-0162-5
doi: 10.1038/s41397-020-0162-5
pubmed: 32042096
pmcid: 7417282
Kazi DS, Garber AM, Shah RU et al (2014) Cost-effectiveness of genotype-guided and dual antiplatelet therapies in acute coronary syndrome. Ann Intern Med 160(4):221–232. https://doi.org/10.7326/M13-1999
doi: 10.7326/M13-1999
pubmed: 24727840
Sibbing D, Aradi D, Alexopoulos D et al (2019) Updated Expert Consensus Statement on platelet function and genetic testing for guiding P2Y12 receptor inhibitor treatment in percutaneous coronary intervention. JACC Cardiovasc Interv 12(16):1521–1537. https://doi.org/10.1016/j.jcin.2019.03.034
doi: 10.1016/j.jcin.2019.03.034
pubmed: 31202949
Young CC, Bass DI, Cruz MJ et al (2022) Clopidogrel hyper-response increases peripheral hemorrhagic complications without increasing intracranial complications in endovascular aneurysm treatments requiring dual antiplatelet therapy. J Clin Neurosci 105:66–72. https://doi.org/10.1016/j.jocn.2022.09.005
doi: 10.1016/j.jocn.2022.09.005
pubmed: 36113244
Higashiguchi S, Sadato A, Nakahara I et al (2021) Reduction of thromboembolic complications during the endovascular treatment of unruptured aneurysms by employing a tailored dual antiplatelet regimen using aspirin and prasugrel. J Neurointerv Surg 13(11):1044–1048. https://doi.org/10.1136/neurintsurg-2020-016994
doi: 10.1136/neurintsurg-2020-016994
pubmed: 33632886
pmcid: 8526880
Kim KS, Fraser JF, Grupke S, Cook AM (2018) Management of antiplatelet therapy in patients undergoing neuroendovascular procedures. J Neurosurg 129(4):890–905. https://doi.org/10.3171/2017.5.JNS162307
doi: 10.3171/2017.5.JNS162307
pubmed: 29192856
Lhermusier T, Lipinski MJ, Tantry US et al (2015) Meta-analysis of direct and indirect comparison of ticagrelor and prasugrel effects on platelet reactivity. Am J Cardiol 115(6):716–723. https://doi.org/10.1016/j.amjcard.2014.12.029
doi: 10.1016/j.amjcard.2014.12.029
pubmed: 25728845
Krishnan K, Nguyen TN, Appleton JP et al (2023) Antiplatelet Resistance: a review of concepts, mechanisms, and implications for management in Acute ischemic stroke and transient ischemic attack. Stroke: Vascular Interventional Neurol 3(3):e000576. https://doi.org/10.1161/SVIN.122.000576
doi: 10.1161/SVIN.122.000576
Brandt JT, Close SL, Iturria SJ et al (2007) Common polymorphisms of CYP2C19 and CYP2C9 affect the pharmacokinetic and pharmacodynamic response to clopidogrel but not prasugrel. J Thromb Haemost 5(12):2429–2436. https://doi.org/10.1111/j.1538-7836.2007.02775.x
doi: 10.1111/j.1538-7836.2007.02775.x
pubmed: 17900275
Mega JL, Close SL, Wiviott SD et al (2009) Cytochrome P450 genetic polymorphisms and the response to prasugrel: relationship to pharmacokinetic, pharmacodynamic, and clinical outcomes. Circulation 119(19):2553–2560. https://doi.org/10.1161/CIRCULATIONAHA.109.851949
doi: 10.1161/CIRCULATIONAHA.109.851949
pubmed: 19414633
Flechtenmacher N, Kämmerer F, Dittmer R et al (2015) Clopidogrel Resistance in Neurovascular Stenting: correlations between light transmission aggregometry, VerifyNow, and the Multiplate. AJNR Am J Neuroradiol 36(10):1953–1958. https://doi.org/10.3174/ajnr.A4388
doi: 10.3174/ajnr.A4388
pubmed: 26272977
pmcid: 7965050
Akbari SH, Reynolds MR, Kadkhodayan Y, Cross DT, Moran CJ (2013) Hemorrhagic complications after prasugrel (effient) therapy for vascular neurointerventional procedures. J Neurointerv Surg 5(4):337–343. https://doi.org/10.1136/neurintsurg-2012-010334
doi: 10.1136/neurintsurg-2012-010334
pubmed: 22555594
Kitazono T, Toyoda K, Kitagawa K et al (2021) Efficacy and safety of Prasugrel by Stroke Subtype: a Sub-analysis of the PRASTRO-I randomized controlled trial. J Atheroscler Thromb 28(2):169–180. https://doi.org/10.5551/jat.56093
doi: 10.5551/jat.56093
pubmed: 32493881
pmcid: 7957026
Chalouhi N, Tjoumakaris S, Phillips JLH et al (2014) A single pipeline embolization device is sufficient for treatment of intracranial aneurysms. AJNR Am J Neuroradiol 35(8):1562–1566. https://doi.org/10.3174/ajnr.A3957
doi: 10.3174/ajnr.A3957
pubmed: 24788125
pmcid: 7964452
Stetler WR, Chaudhary N, Thompson BG, Gemmete JJ, Maher CO, Pandey AS (2013) Prasugrel is effective and safe for neurointerventional procedures. J Neurointerv Surg 5(4):332–336. https://doi.org/10.1136/neurintsurg-2012-010302
doi: 10.1136/neurintsurg-2012-010302
pubmed: 22619468
Daou B, Starke RM, Chalouhi N et al (2016) P2Y12 reaction units: Effect on Hemorrhagic and Thromboembolic complications in patients with cerebral aneurysms treated with the Pipeline Embolization device. Neurosurgery 78(1):27. https://doi.org/10.1227/NEU.0000000000000978
doi: 10.1227/NEU.0000000000000978
pubmed: 26571145
Guédon A, Clarençon F, Maria FD et al (2016) Very late ischemic complications in flow-diverter stents: a retrospective analysis of a single-center series. J Neurosurg 125(4):929–935. https://doi.org/10.3171/2015.10.JNS15703
doi: 10.3171/2015.10.JNS15703
pubmed: 26824382
Sardella G, Calcagno S, Mancone M et al (2012) Pharmacodynamic effect of switching therapy in patients with high on-treatment platelet reactivity and genotype variation with high clopidogrel dose versus prasugrel: the RESET GENE trial. Circ Cardiovasc Interv 5(5):698–704. https://doi.org/10.1161/CIRCINTERVENTIONS.112.972463
doi: 10.1161/CIRCINTERVENTIONS.112.972463
pubmed: 23048056
Enomoto Y, Matsubara H, Ishihara T et al (2024) Optimal duration of dual antiplatelet therapy for stent-assisted coiling or flow diverter placement. J Neurointerv Surg 16(5):491–497. https://doi.org/10.1136/jnis-2023-020285 PMID: 37344176; PMCID: PMC11041548
doi: 10.1136/jnis-2023-020285
pubmed: 37344176