Pharmacogenetic-guided antiplatelet therapy for personalized medicine in patients with stroke and transient ischemic attack without cardioembolic stroke: A systematic review of economic evaluations

Authors

Nathapol Samprasit, Pharmaceutical Sciences and Management Graduate Program Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, ThailandFollow
Chamipa Phanudulkitti, Department of Social and Administrative Pharmacy Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, ThailandFollow
Nattanichcha Kulthanachairojana, Department of Social and Administrative Pharmacy Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, ThailandFollow
Jatapat Hemapanpairoa, Department of Pharmaceutical care Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, ThailandFollow

Abstract

Background: Stroke is a major global public health burden. Ischemic stroke is the most common type of all stroke cases worldwide. Antiplatelet therapy is a key strategy for secondary prevention in patients with stroke and transient ischemic attacks (TIAs) without cardioembolic stroke. Dual antiplatelet therapy (DAPT) with clopidogrel is recommended in patients with early mild stroke or high-risk TIA, followed by long-term single antiplatelet therapy (SAPT). Clopidogrel is often used as an alternative for patients with aspirin resistance or intolerance. However, clopidogrel is a prodrug metabolized by the CYP2C19 enzyme, leading to variability in its effectiveness.

Objectives: This study aims to review and summarize the economic evaluations of pharmacogenetic (PGx)-guided antiplatelet therapy in patients with stroke and TIA without cardioembolic stroke.

Methods: A systematic literature search of PubMed, ScienceDirect, Scopus, Cochrane Review, Tufts CEA (CEA registry), and PharmGKB from their inception to June 30, 2024. Quality assessment was done using the ECOBIAS tool. The synthesis of evidence was based on incremental cost-effectiveness ratio and incremental net benefit, adjusted to 2023 USD values by the consumer price index.

Results: The search identified 5,843 articles, of which six studies were eligible. Five studies assessed DAPT, whereas one focused on SAPT for recurrent stroke prevention. PGx-guided therapy with alternative antiplatelet agents (dipyridamole, cilostazol, or ticagrelor) was compared to standard clopidogrel therapy. In the SAPT, PGxguided therapy was more costly but provided more QALYs in Asian populations (Chinese, Indian, and Malaysian). In Canada, Singapore, and China, PGx-guided DAPT was more cost-effective, whereas in the UK, PGx-guided dipyridamole was cost-saving.

Conclusion: PGx-guided DAPT with cilostazol, ticagrelor, or clopidogrel can be cost-effective or cost-saving compared to universal clopidogrel. PGx-guided SAPT with ticagrelor in patients with loss-of-function polymorphisms and normal metabolizers may also be cost-effective, though the evidence is of low certainty.

DOI

10.56808/3027-7922.3004

Recommended Citation

Samprasit, Nathapol; Phanudulkitti, Chamipa; Kulthanachairojana, Nattanichcha; and Hemapanpairoa, Jatapat (2025) "Pharmacogenetic-guided antiplatelet therapy for personalized medicine in patients with stroke and transient ischemic attack without cardioembolic stroke: A systematic review of economic evaluations," The Thai Journal of Pharmaceutical Sciences: Vol. 49: Iss. 2, Article 4.
DOI: https://doi.org/10.56808/3027-7922.3004
Available at: https://digital.car.chula.ac.th/tjps/vol49/iss2/4