Department of Neurology (SGH Campus), National Neuroscience Institute, Singapore.
Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
Int J Stroke. 2024 Feb;19(2):209-216. doi: 10.1177/17474930231202374. Epub 2023 Sep 29.
Patients with minor ischemic stroke or transient ischemic attacks (TIAs) are often treated with dual antiplatelet therapy regimens as part of secondary stroke prevention. Clopidogrel, an antiplatelet used in these regimens, is metabolized into its active form by the enzyme. Patients with loss of function (LOF) mutations in are at risk for poorer secondary outcomes when prescribed clopidogrel.
We aimed to determine the cost-effectiveness of three different treatment antiplatelet regimens in ischemic stroke populations with minor strokes or TIAs and how these treatment regimens are influenced by the LOF prevalence in the population.
Markov models were developed to look at the cost-effectiveness of empiric treatment with aspirin and clopidogrel versus empiric treatment with aspirin and ticagrelor, versus genotype-guided therapy for either 21 or 30 days. Effect ratios were obtained from the literature, and incidence rates and costs were obtained from the national data published by the Singapore Ministry of Health. The primary endpoints were the incremental cost-effectiveness ratios (ICERs).
Empiric treatment with aspirin and ticagrelor was the most cost-effective treatment. Genotype-guided therapy was more cost-effective than empiric aspirin and clopidogrel if the LOF was above 48%. Empiric ticagrelor and aspirin was cost saving when compared to genotype-guided therapy. Results in models of dual antiplatelet therapy for 30 days were similar.
This study suggests that in patients with minor stroke and TIA planned for dual antiplatelet regimens, empiric ticagrelor and aspirin is the most cost-effective treatment regimen. If ticagrelor is not available, genotype-guided therapy is the most cost-effective treatment regimen if the LOF prevalence in the population is more than 48%.
轻度缺血性卒中和短暂性脑缺血发作（TIA）患者常采用双联抗血小板治疗方案进行二级卒中预防。这些方案中使用的抗血小板药物氯吡格雷，由酶代谢为其活性形式。携带 基因功能丧失（LOF）突变的患者在使用氯吡格雷时，二级转归风险较高。
我们旨在确定三种不同的抗血小板治疗方案在轻度卒中和 TIA 缺血性卒中人群中的成本效益，以及这些治疗方案如何受到人群中 LOF 流行率的影响。
采用 Markov 模型，评估经验性阿司匹林联合氯吡格雷治疗与经验性阿司匹林联合替格瑞洛治疗，以及 21 或 30 天基因型指导治疗的成本效益。从文献中获得疗效比，从新加坡卫生部公布的国家数据中获得发病率和成本。主要终点为增量成本效益比（ICER）。
经验性阿司匹林联合替格瑞洛治疗是最具成本效益的治疗方法。如果 LOF 高于 48%，则基因型指导治疗比经验性阿司匹林联合氯吡格雷治疗更具成本效益。与基因型指导治疗相比，经验性替格瑞洛联合阿司匹林治疗具有成本效益。在 30 天双联抗血小板治疗模型中，结果相似。
本研究表明，对于计划接受双联抗血小板治疗方案的轻度卒中和 TIA 患者，经验性替格瑞洛联合阿司匹林是最具成本效益的治疗方案。如果替格瑞洛不可用，如果人群中 LOF 的流行率超过 48%，则基因型指导治疗是最具成本效益的治疗方案。
