PharmacoEconomics & Outcomes News 784, p28 - 12 Aug 2017
Ticagrelor cost effective in
high risk subgroups?
Dual antiplatelet therapy with ticagrelor and low-dose
aspirin one to three years after myocardial infarction
(MI) may be cost effective in high-risk subgroups,
according to findings of a cost-utility substudy of the
trial published in the Journal of the
American College of Cardiology.
The prospective, randomised PEGASUS-TIMI 54 trial
in a total of 21 162 patients after MI showed that
ticagrelor 90 or 60 mg/day and low-dose aspirin
improved cardiovascular outcomes compared with
aspirin alone. An in-trial analysis in 14 111 patients
compared the cost effectiveness of ticagrelor 60mg
twice daily or placebo, in addition to aspirin, from the
perspective of the US healthcare system over a median
follow-up period of 33 months. Investigators also used a
Markov model to evaluate the long-term
cost effectiveness of ticagrelor 60mg twice daily versus
placebo, from a modified societal perspective over a
lifetime time horizon.
In the in-trial analysis, there was no significant
difference in hospitalisation costs between ticagrelor
and placebo ($2262
vs $2333) and the QALY gain was
similar (2.28 vs 2.27) but total costs were higher with
ticagrelor ($10 016 vs $2333; p<0.001) due to the drug
cost ($10.52 per day).
Over a lifetime, ticagrelor was estimated to achieve an
incremental gain of 0.078 QALYs compared with
placebo at an incremental cost of $7435, resulting in an
estimated incremental cost-effectiveness ratio (ICER) of
$94 917 per QALY gained. However, ICERs were lower
in high-risk patients including those with two or more
previous MIs, multivessel disease, diabetes mellitus or
renal impairment ($50 000
$70 000 per QALY gained),
aged under 75 years ($44 779 per QALY gained), or with
peripheral artery disease ($13 427 per QALY gained).
"Compared with aspirin alone, addition of ticagrelor in
patients with a history of MI >1 year previously is
associated with a cost-effectiveness ratio suggesting
intermediate value. Ticagrelor has greater value for
higher-risk patients," the investigators concluded.
"Based on the results of the current study, from a cost-
effective perspective, it appears reasonable to continue
ticagrelor beyond 1 year in the patients with only the
highest ischemic risk. These findings highlight the
importance of careful scrutiny of eligibility as applied to
individual patients in routine practice," commented
Drs Eliano Navarese from Inova Heart and Vascular
Institute, Falls Church, Virginia, and Jan Tijssen, from
Academic Medical Center-University of Amsterdam,
Naarden, the Netherlands, in accompanying editorial
published in the Journal of the American College of
* Prevention of Cardiovascular Events in Patients With Prior Heart
Attack Using Ticagrelor Compared to Placebo on a Background of
Aspirin–Thrombolysis In Myocardial Infarction 54
** 2016 US dollars
1. Magnuson EA, et al. Cost-Effectiveness of Long-Term Ticagrelor in Patients
With Prior Myocardial Infarction : Results From the PEGASUS-TIMI 54 Trial.
Journal of the American College of Cardiology 70: 527-538, No. 5, 1 Aug 2017.
Available from: URL: https://doi.org/10.1016/j.jacc.2017.05.063.
2. Navarese EP, et al. Striking the Balance Between Benefits and Costs of
Ticagrelor Beyond 1 Year After Myocardial Infarction. Journal of the American
College of Cardiology 70: 539-541, No. 5, 1 Aug 2017. Available from: URL:
PharmacoEconomics & Outcomes News 12 Aug 2017 No. 7841173-5503/17/0784-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved