Cost-Effectiveness of Platelet Function Testing in Dual Antiplatelet Therapy Decision-Making after Intracranial Aneurysm Treatment with Flow Diversion

Abstract

AbstractIntroductionDual 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 asses patient responsiveness to DAPT. Clopidogrel is the most commonly prescribed drug during DAPT, yet up to 52% of patients can be non-responders justifying PFT. 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 ICA treatment.MethodsA 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.ResultsPFT-Prasugrel was the most cost-effective regimen compared to universal Clopidogrel, with a base-case incremental cost-effectiveness ratio (ICER) of $-35,255 (cost $2336.67, effectiveness 0.85). PFT-Ticagrelor (ICER $-4,671; cost $2,995.06, effectiveness 0.84), universal Prasugrel (ICER $5,553; cost $3,097.30, effectiveness 0.84), and 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.ConclusionThe most cost-effective strategy for DAPT after FD for intracranial aneurysms is administering PFT-Prasugrel alongside aspirin. The cost of PFT is strongly justified and recommended when deciding patient-specific DAPT regimens.