National Institute for Health and Clinical Excellence (NICE)
NICE recommends prasugrel (Efient) for preventing blood clots in people with acute coronary syndromes
Healthcare guidance body NICE has reviewed its guidance on prasugrel (Efient, Eli Lilly and Company). The updated guidance published recently recommends the drug in combination with aspirin for preventing blood clots in people who have had a heart attack or who have unstable angina (collectively called acute coronary syndromes) and who are also having a procedure to widen narrowed arteries in the heart (percutaneous coronary interventioni).
Acute coronary syndromes are caused when a blood clot causes one of the large blood vessels that carry oxygen-rich blood to the heart to become narrowed or blocked. This reduces blood flow to the heart and the part of the heart affected can become permanently damaged.
Where the blood supply to the heart is blocked but there is no evidence of actual damage to the heart muscle, it is described as unstable angina. ST-segment-elevation myocardial infarction (STEMI) and Non-ST-segment-elevation myocardial infarction (NSTEMI) – the names come from the pattern seen on an ECG, which measures the rhythm and electrical activity of the heart – are types of heart attack that happen when the blockage in the blood vessel results in damage to the heart muscle.
Prasugrel belongs to a class of drugs called anti-platelets. These work by reducing or preventing the formation of blood clots, so that blood flow to the heart muscle can be maintained to prevent further damage.
Commenting on the guidance, Professor Carole Longson, Director of the Centre for Health Technology Evaluation at NICE, said: “This review assessed the clinical and cost effectiveness of prasugrel, noting that since the original guidance was published in 2009 NICE has also published guidance on the use of ticagrelor for the same indication, and the price of another drug, clopidogrel, has reduced as generic versions have become available. Taking these factors into consideration, we are now recommending prasugrel as an option for more people with acute coronary syndromes than our previous guidance.
“The Committee also heard from clinical experts that the faster action of prasugrel compared to clopidogrel could be an advantage for STEMI patients who need immediate percutaneous coronary intervention. The guidance also recommends prasugrel as an option for people with NSTEMI and unstable angina, with or without diabetes.”
Notes to Editors
References and explanation of terms
i. This guidance refers specifically to people with acute coronary syndromes who are having an invasive treatment known as percutaneous coronary intervention, also known as angioplasty. Percutaneous coronary intervention is a treatment for heart problems, which opens up the narrowed arteries so that blood flows more easily to the heart muscle and may include a small mesh-like tube called a stent being inserted into an artery to keep it open.
About the guidance
- The guidance on prasugrel is available from 00:01 on Wednesday 23 July 2014.
- Acute coronary syndromes are usually the result of a reduction of oxygen supply to the heart usually caused by a blood clot that forms on a patch of atheroma (build-up of material in a heart vessel) in one of the coronary arteries.
- Treatment with antiplatelet therapy is an established adjunct to percutaneous coronary intervention both before and for up to 12 months after the procedure (NICE CG167 and NICE CG94). The purpose of antiplatelet treatment is to inhibit the aggregation of platelets that can lead to thrombus formation and further vascular events including stent thrombosis. Dual antiplatelet therapy, aspirin plus prasugrel, clopidogrel or ticagrelor is the standard antiplatelet treatment in clinical practice in the UK.
- Long term management of acute coronary syndromes includes the use of aspirin plus a thienopyridine (clopidogrel, prasugrel) or acyclopentyl-triazolo-pyrimidine (ticagrelor). NICE has produced clinical guidelines on ‘Myocardial infarction with ST-segment-elevation: The acute management of myocardial infarction with ST-segment-elevation’ (NICE clinical guideline 167) and on ‘Unstable angina and NSTEMI: the early management of unstable angina and non-ST-segment-elevation myocardial infarction’ (NICE clinical guideline 94).
- Previous NICE guidance recommended prasugrel in combination with aspirin as an option for preventing atherothrombotic events in people with acute coronary syndromes having percutaneous coronary intervention, only when: immediate primary percutaneous intervention for STEMI is necessary, stent thrombosis has occurred during clopidogrel treatment or the patient has diabetes (NICE technology appraisal guidance 182). NICE also recommends ticagrelor in combination with low-dose aspirin for up to 12 months as an option for people with STEMI who are to be treated with percutaneous coronary intervention, NSTEMI or unstable angina (NICE technology appraisal guidance 236).
- The price of prasugrel is £47.56 per 28-tab pack (excluding VAT, 'British national formulary' [BNF] edition 66). The cost of treatment for 12 months is £628.48 (excluding VAT). Costs may vary in different settings because of negotiated procurement discounts.
- The ICERs for all 4 of the subgroups (STEMI with diabetes, STEMI without diabetes, unstable angina or NSTEMI with diabetes, unstable angina and NSTEMI without diabetes) were lower than £20,000 per QALY gained. For patients with unstable angina or NSTEMI and diabetes, prasugrel dominated (that is, it was more effective and less costly than) clopidogrel.
- In England it is estimated that there are approximately 82,000 MIs every year. Of the 80,974 hospital admissions with a final diagnosis of myocardial infarction recorded in the Myocardial Ischaemia National Audit Project (MINAP), 40% were STEMIs and 60% were NSTEMIs. The average age of people with STEMI and NSTEMI was 65 years and 72 years respectively. Twice as many men had MIs as women.
- In England, there were 32,000 hospital admissions for unstable angina in 2012/13.
The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.
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