College of Pharmacy, QU Health, Qatar University, Doha, Qatar.
J Cardiovasc Pharmacol Ther. 2020 May;25(3):201-211. doi: 10.1177/1074248420902298. Epub 2020 Feb 6.
Clopidogrel is widely used after the percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and requires activation by cytochrome P450 (CYP), primarily CYP2C19. Patients with CYP2C19 loss-of-function alleles are at increased risk of major adverse cardiovascular events, while more expensive novel antiplatelet agents (ticagrelor and prasugrel) are unaffected by the CYP2C19 mutations. This systematic review aims to answer the question about whether overall evidence supports the genotype-guided selection of antiplatelet therapy as a cost-effective strategy in post-PCI ACS.
A systematic literature search of PubMed, EMBASE, EconLit, and PharmGKB was done to identify all the economic evaluations related to genotype-guided therapy compared to the universal use of antiplatelets in ACS patients. Quality of Health Economic Studies tool was used for quality assessment.
The search identified 13 articles, where genotype-guided treatment was compared to universal clopidogrel, ticagrelor, and/or prasugrel. Six studies showed that genotype-guided therapy was cost-effective compared to universal clopidogrel, while 5 studies showed that it was dominant. One study specified that genotype-guided with ticagrelor is cost-effective only in both CYP2C19 intermediate and poor metabolizers. Genotype-guided therapy was dominant when compared to universal prasugrel, ticagrelor, or both in 5, 1, and 3 studies, respectively. Only 2 studies reported that universal ticagrelor was cost-effective compared to genotype-guided treatment. All the included articles had good quality.
Based on current economic evaluations in the literature, implementing CYP2C19 genotype-guided therapy is a cost-effective approach in guiding the selection of medication in patients with ACS undergoing PCI.
氯吡格雷在急性冠脉综合征（ACS）患者经皮冠状动脉介入治疗（PCI）后广泛应用，需要细胞色素 P450（CYP）代谢，主要是 CYP2C19。CYP2C19 功能丧失等位基因的患者发生主要不良心血管事件的风险增加，而更昂贵的新型抗血小板药物（替格瑞洛和普拉格雷）不受 CYP2C19 突变的影响。本系统评价旨在回答以下问题：总体证据是否支持基于基因型的抗血小板治疗作为 PCI 后 ACS 的一种具有成本效益的策略。
对 PubMed、EMBASE、EconLit 和 PharmGKB 进行系统文献检索，以确定所有与基因型指导治疗相关的经济评估，与 ACS 患者普遍使用抗血小板药物进行比较。使用卫生经济研究质量工具进行质量评估。
搜索共确定了 13 篇文章，其中基因型指导治疗与普遍使用氯吡格雷、替格瑞洛和/或普拉格雷进行了比较。6 项研究表明，与普遍使用氯吡格雷相比，基因型指导治疗具有成本效益，而 5 项研究表明其具有优势。一项研究表明，基因型指导与替格瑞洛联合治疗仅在 CYP2C19 中间代谢和弱代谢者中具有成本效益。与普遍使用普拉格雷、替格瑞洛或两者相比，5、1 和 3 项研究分别表明基因型指导治疗具有优势。只有 2 项研究报告称普遍使用替格瑞洛与基因型指导治疗相比具有成本效益。所有纳入的文章质量都很好。
根据目前文献中的经济评估，实施 CYP2C19 基因型指导治疗是指导 ACS 患者 PCI 后药物选择的一种具有成本效益的方法。
