Scientific Poster Session IV - Encore

Encore Presentations
  Tuesday, October 15, 2024
  08:30 AM–10:00 AM

Abstract

Background:
Tailored P2Y12 inhibitor therapy is gaining popularity and is described as a method to balance safe and effective prescribing of clopidogrel. Based on previous work, 28% of our patients with CYP2C19 genotyping do not metabolize clopidogrel effectively (intermediate or poor metabolizers).
Aim:
We aim to describe the economic impact of a guided P2Y12 inhibitor strategy and the practice of escalation (clopidogrel to ticagrelor/prasugrel) and de-escalation (ticagrelor/prasugrel to clopidogrel) practices at a single health system. We hypothesize a guided approach is economically feasible vs. a universal ticagrelor or prasugrel approach. We also aim to determine how quickly clinicians escalate or de-escalate in response to CYP2C19 results.
Methods:
3-year (2020-2022) data was collected from our EMR. Annually an average of 950 patients received CYP2C19testing to guide P2Y12 inhibitor therapy (n=2799), and an average of 316 patients were either escalated or de-escalated (n=949). Of the 2799 patients, clopidogrel was most often the initial P2Y12 inhibitor (n=2240), followed by ticagrelor (n=525), and prasugrel (n=34). We estimated overall medication and CYP2C19 testing costs over the course of an average year (Figure 1) based on the assumption that over the course of 1-year patients would begin on 30 days of either ticagrelor, prasugrel, or clopidogrel and escalate/de-escalate therapy thereafter as guided by testing.
Results:
The time to escalation was similar if the CYP2C19 result was ordered before or after the first order for P2Y12 inhibitor therapy, median of 6.2 and 6.5 days respectively (p = .07). There was a difference in time to de-escalation based on time of CYP2C19 testing in comparison to medication ordering with a median time of 32.1 and 8 days when testing was ordered before initiation and after, respectively (p <.001).
Conclusion:
Overall, clinicians were highly responsive to CYP2C19 test results for both escalation and de-escalation of therapy.

	Approach
P2Y12 Inhibitor	Universal Ticagrelor	Universal Prasugrel	Genotype Guided: Ticagrelor to Clopidogrel	Genotype Guided: Prasugrel to Clopidogrel	Genotype Guided: Clopidogrel to Ticagrelor	Genotype Guided: Clopidogrel to Prasugrel
	Annual Costs
Clopidogrel 75 mg daily			$ 13,542	$ 13,542	$15,242	$15,242
Prasugrel 10mg daily		$114,342		$ 38,463		$28,934
Ticagrelor 90mg twice daily	$ 4,647,666		$ 1,563,392		$1,176,086
CYP2C19 Testing			$ 237,500	$ 237,500	$ 237,500	$ 237,500
Total	$ 4,647,666	$ 114,342	$ 1,814,434	$ 289,504	$1,428,829	$281,676
Annual Costs for 950 patients (Average single gene CYP2C19 orders at our institution over 2020, 2021, and 2022) CYP2C19 test cost: estimated $250 Medication costs per CMS data as of December 2022

Presenting Author

Amanda Massmann PharmD
Sanford Health

Authors

Catherine Hajek MD
Sanford Health

Andrii Maryniak MD
Sanford Health

April Schultz PharmD
Tomasz Stys MD
Sanford Health

Joel Van Heukelom PharmD, MBA
Max Weaver MS
Sanford Health