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Girardin FR, Poncet A, Perrier A, Vernaz N, Pletscher M, F Samer C, Lieberman JA, Villard J. Cost-effectiveness of HLA-DQB1/HLA-B pharmacogenetic-guided treatment and blood monitoring in US patients taking clozapine. THE PHARMACOGENOMICS JOURNAL 2018; 19:211-218. [PMID: 29298994 PMCID: PMC6462824 DOI: 10.1038/s41397-017-0004-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 08/18/2017] [Accepted: 09/18/2017] [Indexed: 12/31/2022]
Abstract
Less than 1% of adult patients with schizophrenia taking clozapine develop agranulocytosis, and most of these cases occur within the first weeks of treatment. The human leukocyte antigen (HLA) region has been associated with genetic susceptibility to clozapine-induced agranulocytosis (single amino acid changes in HLA-DQB1 (126Q) and HLA-B (158T)). The current study aimed to evaluate the cost-effectiveness, from a healthcare provider’s perspective, of an HLA genotype-guided approach in patients with treatment-resistant schizophrenia who were taking clozapine and to compare the results with the current absolute neutrophil count monitoring (ANCM) schemes used in the USA. A semi-Markovian model was developed to simulate the progress of a cohort of adult men and women who received clozapine as a third-line antipsychotic medication. We compared current practices using two genotype-guided strategies: (1) HLA genotyping followed by clozapine, with ANCM only for patients who tested positive for one or both alleles (genotype-guided blood sampling); (2) HLA genotyping followed by clozapine for low-risk patients and alternative antipsychotics for patients who tested positive (clozapine substitution scheme). Up to a decision threshold of $3.9 million per quality-adjusted life-year (90-fold the US gross domestic product per capita), the base-case results indicate that compared with current ANCM, genotype-guided blood sampling prior to clozapine initiation appeared cost-effective for targeted blood monitoring only in patients with HLA susceptibility alleles. Sensitivity analysis demonstrated that at a cost of genotype testing of up to USD700, HLA genotype-guided blood monitoring remained a cost-effective strategy compared with either current ANCM or clozapine substitution.
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Affiliation(s)
- François R Girardin
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Intensive Care, and Clinical Pharmacology, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland. .,Medical Direction, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.
| | - Antoine Poncet
- The Clinical Research Centre, Division of Clinical Epidemiology, Department of Health and Community Medicine, University of Geneva and University Hospitals of Geneva, Geneva, Switzerland
| | - Arnaud Perrier
- Medical Direction, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.,Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Geneva Faculty of Medicine, Geneva, Switzerland
| | - Nathalie Vernaz
- Medical Direction, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.,Finance Direction, University Hospitals and University of Geneva, 1205, Geneva, Switzerland
| | - Mark Pletscher
- Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Intensive Care, and Clinical Pharmacology, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Jeffrey A Lieberman
- Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Jean Villard
- Division of Nephrology, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
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