Budget impact analysis of antiplatelet therapy with cangrelor in patients with acute coronary artery disease undergoing percutaneous coronary intervention in Belgium
Authors: Lizano-Diez I , Paz S 
Published: April 2021

Abstract

Funding Acknowledgements
Type of funding sources: Private company. Main funding source(s): Ferrer, Barcelona, Spain

Background
Cangrelor is a novel, intravenous, potent, fast onset, direct-acting, P2Y12 receptor antagonist that blocks adenosine diphosphate-induced platelet activation and aggregation with a half-life of 3-6 min. Co-administered with acetylsalicylic acid, it is indicated for reducing thrombotic cardiovascular events in patients with coronary artery disease (CAD) (ST-elevation myocardial infarction (STEMI), non-STEMI, stable CAD) undergoing percutaneous coronary intervention (PCI) who have not received an oral P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) prior to PCI procedure and in whom oral therapy with P2Y12 inhibitors is not feasible or desirable.

Purpose
To assess the economic implications of incorporating cangrelor into the hospital formulary for the acute care of CAD patients undergoing PCI in Belgium.

Methods
A budget impact model (BIM) was developed. The 3-year pharmacological and clinical event costs of two hypothetical scenarios, without and with cangrelor in the formulary for the total PCI population (base case) in Belgium were compared. Also, the primary PCI (STEMI) and a PCI population with special needs (e.g., unable to swallow) were assessed as complementary setups. Epidemiological, efficacy (stent thrombosis, myocardial infarction (MI), ischaemia-driven revascularization, death), safety (Thrombolysis in Myocardial Infarction (TIMI) bleeding criteria) and costs (€, 2019) data were based on clinical trials, meta-analyses and on Belgian registries. Only the pharmacological costs of pre-treatment (preload) with oral P2Y12 inhibitors and glycoprotein IIb-IIIa inhibitors (GPI) for bail-out were considered. One-way sensitivity analysis established the effect of uncertainty on BIM results.

Results
The model assumes that the primary PCI population grows from 4,790 to 4,935 adults (age 68 years, mean) over three years in Belgium. Pre-treatment with oral P2Y12 inhibitors increases from 3,544 to 3,652 patients, and uptake of cangrelor rises from 20.60% to 38.30% in the same period. The number of primary PCI patients receiving cangrelor grows from 730 to 1,399. At current usage of antithrombotics and at existing pharmacological and management costs, adding cangrelor into the hospital formulary represents 1.1 million euros over 3 years in Belgium. 6 additional stent thromboses, 3 ischaemia-driven revascularisations and 2 cardiovascular related deaths are avoided while three extra minor bleedings occur over 3 years. Similar pharmacoeconomic findings emerge in the base case and complementary setups. Results are most sensible to the percentage of patients on GPI bail-out.

Conclusions
Under BIM assumptions, introducing cangrelor for the acute care of CAD patients undergoing primary PCI represents a safe and affordable option in Belgium, particularly when the required control of thrombosis is not certain with oral pre-treatment.