Cost-effectiveness of using pharmacogenetic information in warfarin dosing for patients with nonvalvular atrial fibrillation.

摘要

BACKGROUND: Variants in genes involved in warfarin metabolism and sensitivity affect individual warfarin requirements and the risk for bleeding. Testing for these variant alleles might allow more personalized dosing of warfarin during the induction phase. In 2007, the U.S. Food and Drug Administration changed the labeling for warfarin (Coumadin, Bristol-Myers Squibb, Princeton, New Jersey), suggesting that clinicians consider genetic testing before initiating therapy. OBJECTIVE: To examine the cost-effectiveness of genotype-guided dosing versus standard induction of warfarin therapy for patients with nonvalvular atrial fibrillation. DESIGN: Markov state transition decision model. DATA SOURCES: MEDLINE searches and bibliographies from relevant articles of literature published in English. TARGET POPULATION: Outpatients or inpatients requiring initiation of warfarin therapy. The base case was a man age 69 years with newly diagnosed nonvalvular atrial fibrillation and no contraindications to warfarin therapy. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. INTERVENTION: Genotype-guided dosing consisting of genotyping for CYP2C9*2, CYP2C9*3, and/or VKORC1 versus standard warfarin induction. OUTCOME MEASURES: Effectiveness was measured in quality-adjusted life-years (QALYs), and costs were in 2007 U.S. dollars. RESULTS: In the base case, genotype-guided dosing resulted in better outcomes, but at a relatively high cost. Overall, the marginal cost-effectiveness of testing exceeded Dollars 170 000 per QALY. On the basis of current data and cost of testing (about Dollars 400), there is only a 10% chance that genotype-guided dosing is likely to be cost-effective (that is,