Prasugrel (Efient®) with percutaneous coronary intervention for treating acute coronary syndromes (review of TA182): systematic review and economic analysis

摘要: BACKGROUND Acute coronary syndromes (ACSs) are life-threatening conditions associated with acute myocardial ischaemia. There three main types of ACS: ST segment elevation infarction (STEMI), non-ST (NSTEMI) and unstable angina (UA). One treatment for ACS is percutaneous intervention (PCI) plus adjunctive antiplatelet drugs. Dual therapy [aspirin either prasugrel (Efient(®), Daiichi Sankyo Company Ltd UK/Eli Lilly Ltd), clopidogrel or ticagrelor (Brilique(®), AstraZeneca)] standard in UK clinical practice. Prasugrel the focus this review. OBJECTIVES The remit to appraise effectiveness cost-effectiveness within its licensed indication PCI a review National Institute Health Care Excellence technology appraisal TA182. DATA SOURCES Four electronic databases (MEDLINE, EMBASE, Cochrane Library, PubMed) were searched from database inception June 2013 randomised controlled trials (RCTs) August economic evaluations comparing patients undergoing PCI. METHODS Clinical outcomes included non-fatal fatal cardiovascular (CV) events, adverse effects health-related quality life (HRQoL). Cost-effectiveness incremental cost per life-year gained quality-adjusted (QALY) gained. An independent model assessed four mutually exclusive subgroups: treated STEMI without diabetes mellitus UA NSTEMI mellitus. RESULTS No new RCTs identified beyond that reported TRITON-TIMI 38 (Trial Assess Improvement Therapeutic Outcomes by Optimizing Platelet Inhibition Thrombolysis Myocardial Infarction 38) compared scheduled relevant identified. Our analyses focused on key subgroup patients: those aged 60 kg (no previous stroke transient ischaemic attack). For primary composite end point (death CV causes, stroke) statistically significantly fewer events occurred arm (8.3%) than (11%). significant difference major bleeding was noted. However, there favour when minor combined (3.0 vs. 3.9%). conclusions could be drawn regarding HRQoL. results sensitivity confirmed it likely that, all subgroups, 5-10 years cost-effective option at willingness-to-pay threshold £20,000 £30,000 QALY At full 40-year time horizon, estimates < £10,000 LIMITATIONS Lack data precluded comparison ticagrelor; comparative therefore remains unknown. long-term modelling exercise vulnerable assumptions about continuation early health outcome gains. CONCLUSION A strength demonstrates using generic price clopidogrel. Although report gained, Well-audited needed registry defined patient groups who receive prasugrel, STUDY REGISTRATION This study registered as PROSPERO CRD42013005047. FUNDING Research Technology Assessment programme.