双重抗血小板治疗(DAPT)的使用是颅内动脉瘤(IA)分流(FD)后的实践标准。然而,对于最佳方案,文献中没有达成共识.某些机构利用各种血小板功能测试(PFT)来评估患者对DAPT的反应性。氯吡格雷是DAPT期间最常用的处方药;然而,高达52%的患者可能是无应答者,证明PFT使用的合理性。此外,抗血小板药物的价格差异很大,往往因保险限制而进一步复杂化。我们旨在确定IA治疗后患者DAPT方案的最具成本效益的策略。使用蒙特卡罗模拟的决策树来模拟接受各种术后三个月DAPT方案的患者。患者要么与氯吡格雷一起普遍服用阿司匹林,替格瑞洛,或者没有PFT的普拉格雷,或根据氯吡格雷后的血小板反应性单位(PRU)结果给予一种前噻吩并吡啶药物。模型的输入数据是从当前文献中提取的,根据美国的标准做法,支付意愿门槛(WTP)被定义为每QALY100,000美元。基线比较是与没有任何PFT的通用氯吡格雷DAPT。进行了概率和确定性敏感性分析以评估模型的稳健性。与通用氯吡格雷相比,使用PFT并将氯吡格雷转换为普拉格雷(如果有抵抗记录)是最具成本效益的方案,基本情况增量成本效益比(ICER)为-35,255美元(成本2,336.67美元,有效性0.85)。进行PFT并将氯吡格雷转换为替格瑞洛(ICER$-4,671;费用$2,995.06,有效性0.84),通用普拉格雷(ICER5,553美元;费用3,097.30美元,有效性0.84),或普适性替格瑞洛(ICER$75,969;费用$3,801.36,有效性0.84)均比普适性氯吡格雷治疗患者(费用$3,041.77,有效性0.83)更具成本效益.这些结论在概率和确定性敏感性分析中仍然稳健。IAsFD后指导DAPT的最具成本效益的策略是执行PFTs,如果有抵抗记录,则将氯吡格雷转换为普拉格雷,阿司匹林旁边在决定患者特定的DAPT方案时,PFT的费用是有充分理由的,并推荐。
Dual 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 assess patient responsiveness to DAPT. Clopidogrel is the most commonly prescribed drug during DAPT; however, up to 52% of patients can be non-responders, justifying PFT use. 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 IA treatment. A 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. Utilizing PFT and switching clopidogrel to prasugrel if resistance is documented was the most cost-effective regimen compared to universal clopidogrel, with a base-case incremental cost-effectiveness ratio (ICER) of $-35,255 (cost $2,336.67, effectiveness 0.85). Performing PFT and switching clopidogrel to ticagrelor (ICER $-4,671; cost $2,995.06, effectiveness 0.84), universal prasugrel (ICER $5,553; cost $3,097.30, effectiveness 0.84), or 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. The most cost-effective strategy guiding DAPT after FD for IAs is to perform PFTs and switch clopidogrel to prasugrel if resistance is documented, alongside aspirin. The cost of PFT is strongly justified and recommended when deciding patient-specific DAPT regimens.